Most Relevant Information
Provider Data
| NPI Number: | 1003341918 |
| Provider Name: | JONATHAN WICKS ATC, LAT, M.ED |
| Entity Type: | Individual |
| Taxonomy Code: | 2084S0010X |
| Specialty: | Psychiatry & Neurology |
| License Number: | 36002506A |
Most Important Dates
| Enumeration Date: | 04/28/2017 |
| Last Updated: | 04/28/2017 |
Provider Practice Location
1001 E 17TH ST
BLOOMINGTON
IN
474081590
Practice Location Phone/Fax
| Phone: | 8128557920 |
| Fax: |
Provider Mailing Location
2728 S ADAMS ST
UNIT 5
BLOOMINGTON
IN
474033296
Provider Mailing Phone/Fax
| Phone: | 5742509007 |
| Fax: |