Provider Demographics
NPI:1730679051
Name:JONES, LISA RENEE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1504
Mailing Address - Country:US
Mailing Address - Phone:678-688-9685
Mailing Address - Fax:770-626-3791
Practice Address - Street 1:11244 TARA BLVD STE 130
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1655
Practice Address - Country:US
Practice Address - Phone:470-781-3092
Practice Address - Fax:470-781-3094
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN13613363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN13613Medicaid