Provider Demographics
NPI:1578938676
Name:JERRY L JONES MD PROFESSIONAL
Entity Type:Organization
Organization Name:JERRY L JONES MD PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-384-5400
Mailing Address - Street 1:400 SHADOW LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4363
Mailing Address - Country:US
Mailing Address - Phone:702-384-5400
Mailing Address - Fax:702-384-0648
Practice Address - Street 1:400 SHADOW LN
Practice Address - Street 2:SUITE 103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4363
Practice Address - Country:US
Practice Address - Phone:702-384-5400
Practice Address - Fax:702-384-0648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVC96195Medicare UPIN