Provider Demographics
NPI:1093055402
Name:JONES, MATTHEW ROBERT (ACNP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:JONES
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HAMACHER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-4200
Mailing Address - Fax:618-939-4256
Practice Address - Street 1:509 HAMACHER ST STE 202
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-4200
Practice Address - Fax:618-939-4256
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013004685363LA2100X
IL209013655363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108730002Medicare PIN