Individual
MR. JONATHAN TYLER WHITE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
402 CUMBERLAND AVE, WILLIAMSBURG, KY 40769-1238
(606) 549-2656
Mailing address
107 S MAIN ST, JELLICO, TN 37762-2154
(423) 784-8492
(423) 784-8358
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
5318
TN
363A00000X
Physician Assistant
Primary
PA2916
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5318
STATE LICENSE
TN
05
—
7100770770
—
KY
01
—
PA2916
KY MEDICAL LICENSE
KY
01
—
TC120
MEDICAL LICENSE
KY
Enumeration date
06/05/2021
Last updated
05/09/2023
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