Provider Demographics
NPI:1578707121
Name:JONES, BECKY S (COTA)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:S
Last Name:JONES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8510
Mailing Address - Country:US
Mailing Address - Phone:903-561-7835
Mailing Address - Fax:903-561-9878
Practice Address - Street 1:3505 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8510
Practice Address - Country:US
Practice Address - Phone:903-561-7835
Practice Address - Fax:903-561-9878
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210324172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker