Provider Demographics
NPI:1306230982
Name:JONES, LAURENCE ROOSEVELT
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:ROOSEVELT
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 1:112 LONSDALE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1532
Mailing Address - Country:US
Mailing Address - Phone:716-520-7547
Mailing Address - Fax:716-235-8250
Practice Address - Street 1:112 LONSDALE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1532
Practice Address - Country:US
Practice Address - Phone:716-520-7547
Practice Address - Fax:716-235-8250
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093926104100000X
NY275234-1164W00000X
NY08873371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No164W00000XNursing Service ProvidersLicensed Practical Nurse