Jonathan Wicks, ATC, LAT, M.ED

Primary specialty

Sports Medicine (Psychiatry & Neurology) PhysicianTaxonomy code 2084S0010X

License

36002506A Issued in IN

Practice address

1001 E 17TH St
Bloomington, IN 47408-1590

Phone

(812) 855-7920

NPI assigned

Apr 28, 2017

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Education

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1493337600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1493337600000",
    "number": "1003341918",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2728 S ADAMS ST",
            "address_2": "UNIT 5",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474033296",
            "telephone_number": "574-250-9007"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1001 E 17TH ST",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474081590",
            "telephone_number": "812-855-7920"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WICKS",
        "first_name": "JONATHAN",
        "credential": "ATC, LAT, M.ED",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-04-28",
        "last_updated": "2017-04-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084S0010X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Sports Medicine",
            "state": "IN",
            "license": "36002506A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Hayley Rose Wible, D.O.
• Otto William Wickstrom III, M.D.
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• Sports Medicine (Psychiatry & Neurology) Physician in Bloomington, IN
• Providers in Bloomington, IN by specialty
• Sports Medicine (Psychiatry & Neurology) Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 28, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.