Provider Demographics
NPI:1174288948
Name:JONES, JERRY RAY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:RAY
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-2937
Mailing Address - Country:US
Mailing Address - Phone:734-660-2025
Mailing Address - Fax:
Practice Address - Street 1:1670 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2937
Practice Address - Country:US
Practice Address - Phone:608-356-9318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704219859363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health