Provider Demographics
NPI:1093051955
Name:JONES, JACK (HIS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 US HIGHWAY 280
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 ALTAMA CONNECTOR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1888
Practice Address - Country:US
Practice Address - Phone:912-265-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS000746237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist