Provider Demographics
NPI:1003835554
Name:JONES, THERESA L (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:JONES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 74TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9173
Mailing Address - Country:US
Mailing Address - Phone:269-589-8788
Mailing Address - Fax:
Practice Address - Street 1:1447 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4727
Practice Address - Country:US
Practice Address - Phone:989-583-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS41813Medicare UPIN