Provider Demographics
NPI:1164431193
Name:JONES, MANDISA (PT)
Entity Type:Individual
Prefix:
First Name:MANDISA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E PONCE DE LEON AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3488
Mailing Address - Country:US
Mailing Address - Phone:404-377-9107
Mailing Address - Fax:404-377-9109
Practice Address - Street 1:235 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3452
Practice Address - Country:US
Practice Address - Phone:404-377-9107
Practice Address - Fax:404-377-9109
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDTXMedicare ID - Type Unspecified