Provider Demographics
NPI:1598769325
Name:JONES, GEORGINA (RPT)
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31801 HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-9275
Mailing Address - Country:US
Mailing Address - Phone:707-964-1983
Mailing Address - Fax:707-964-2269
Practice Address - Street 1:121 BOATYARD DR
Practice Address - Street 2:STE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5751
Practice Address - Country:US
Practice Address - Phone:707-964-1208
Practice Address - Fax:707-964-2269
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT1679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0016790Medicaid
CAPT0016790Medicaid