Provider Demographics
NPI:1508334723
Name:JONES, EDTH (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDTH
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 E BROOKHAVEN DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1071
Mailing Address - Country:US
Mailing Address - Phone:404-274-4163
Mailing Address - Fax:
Practice Address - Street 1:1244 CLAIRMONT RD STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1263
Practice Address - Country:US
Practice Address - Phone:404-274-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004249103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004249OtherGEORGIA PROFESSIONAL LICENSING BOARD