Provider Demographics
NPI:1376827238
Name:JONES, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WOODBERRY RD
Mailing Address - Street 2:77
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2870
Mailing Address - Country:US
Mailing Address - Phone:803-586-7578
Mailing Address - Fax:
Practice Address - Street 1:1059 MEETING ST.
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170
Practice Address - Country:US
Practice Address - Phone:803-586-7578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7486172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker