Provider Demographics
NPI:1780636209
Name:JONES, BENJAMIN A (PSYD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:JONES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A140
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3585
Practice Address - Country:US
Practice Address - Phone:864-454-5125
Practice Address - Fax:864-241-9201
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC000876208000000X
SC876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0377Medicaid
SCQ340057951Medicare PIN
SCPS0377Medicaid
SCQ34005Medicare UPIN