Provider Demographics
NPI:1275047797
Name:JONES, TERRENCE EDWARD (CPRM)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:EDWARD
Last Name:JONES
Suffix:
Gender:M
Credentials:CPRM
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ADMINSTRATIVE MANAGE
Mailing Address - Street 1:15941 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4123
Mailing Address - Country:US
Mailing Address - Phone:313-345-4310
Mailing Address - Fax:313-345-4315
Practice Address - Street 1:15941 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4123
Practice Address - Country:US
Practice Address - Phone:313-345-4310
Practice Address - Fax:313-345-4315
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0823212175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204986314Medicaid