Provider Demographics
NPI:1114974110
Name:JONES, NICOLETTE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:M
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5415
Mailing Address - Fax:740-446-5958
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5415
Practice Address - Fax:740-446-5958
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20360208800000X
OH35.074405208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000185208OtherUNISON MEDICAID
OH2065465OtherMOLINA MEDICAID
001714105OtherMOUNTAIN STATE BCBS
WV0130533000Medicaid
OH2065465Medicaid
340015105OtherRR MEDICARE
000000007133OtherANTHEM BCBS
OH310917085125OtherCARESOURCE MEDICAID
WV0130533000Medicaid
001714105OtherMOUNTAIN STATE BCBS
OH0855063Medicare PIN