Provider Demographics
NPI:1710264221
Name:JONES, MARY LOU (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:JONES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BOKUM RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1500
Mailing Address - Country:US
Mailing Address - Phone:860-767-9053
Mailing Address - Fax:860-767-1146
Practice Address - Street 1:12 BOKUM RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1500
Practice Address - Country:US
Practice Address - Phone:860-767-9053
Practice Address - Fax:860-767-1146
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400158048Medicare PIN