Provider Demographics
NPI:1043737224
Name:JONES, FRED TIMOTHY (CDCA, CMS)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:TIMOTHY
Last Name:JONES
Suffix:
Gender:M
Credentials:CDCA, CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 TOWNSHIP ROAD 1067
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-7898
Mailing Address - Country:US
Mailing Address - Phone:740-479-8241
Mailing Address - Fax:
Practice Address - Street 1:178 PRIVATE DRIVE 19423
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680
Practice Address - Country:US
Practice Address - Phone:740-263-2626
Practice Address - Fax:740-894-1132
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165754101YA0400X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)