Provider Demographics
NPI:1679504575
Name:JONES, VICKI A (LAC)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:A
Last Name:JONES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 S BROADWAY STE S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6567
Mailing Address - Country:US
Mailing Address - Phone:701-240-3775
Mailing Address - Fax:
Practice Address - Street 1:1809 S BROADWAY STE S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6567
Practice Address - Country:US
Practice Address - Phone:701-240-3775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1493101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054517Medicaid
ND022792OtherBCBS ND PIN