Provider Demographics
NPI:1083327969
Name:HARRISON JONES, ETHEL M
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:M
Last Name:HARRISON JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 N RONALD REAGAN BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3534
Mailing Address - Country:US
Mailing Address - Phone:407-215-0095
Mailing Address - Fax:
Practice Address - Street 1:1105 HILLHURST DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-7170
Practice Address - Country:US
Practice Address - Phone:813-648-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1104910868Medicaid