Provider Demographics
NPI:1790446862
Name:JONES, OCTAVIA
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
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 1:34984 PERSIMMON AVE
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:473 S CARNEGIE DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4201
Practice Address - Country:US
Practice Address - Phone:951-405-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician