Provider Demographics
NPI:1942738208
Name:JONES, ETHAN (MA)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-2351
Mailing Address - Country:US
Mailing Address - Phone:217-821-9434
Mailing Address - Fax:
Practice Address - Street 1:802 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1756
Practice Address - Country:US
Practice Address - Phone:618-283-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011650101YP2500X
IL180011408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional