Provider Demographics
NPI:1790348183
Name:JONES, RICKIE
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 IRA BUNION RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-5349
Mailing Address - Country:US
Mailing Address - Phone:850-321-5617
Mailing Address - Fax:
Practice Address - Street 1:30 IRA BUNION RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-5349
Practice Address - Country:US
Practice Address - Phone:850-321-5617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017681100Medicaid