Provider Demographics
NPI:1457493686
Name:JONES, CAROL SUE (EDD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:SUE
Last Name:JONES
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3200
Mailing Address - Country:US
Mailing Address - Phone:503-288-6066
Mailing Address - Fax:
Practice Address - Street 1:4231 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3200
Practice Address - Country:US
Practice Address - Phone:503-288-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005104103T00000X
OR1973103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR035567000OtherBCBS
MI680C946110OtherBCBSM
OR035567000OtherBCBS