Provider Demographics
NPI:1073800769
Name:JONES, DOUGLAS CARROLL
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CARROLL
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3506
Mailing Address - Country:US
Mailing Address - Phone:612-874-9811
Mailing Address - Fax:612-874-9820
Practice Address - Street 1:1911 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3506
Practice Address - Country:US
Practice Address - Phone:612-874-9811
Practice Address - Fax:612-874-9820
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302811101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302811OtherALCOHOL AND DRUG ABUSE COUNSELOR