Provider Demographics
NPI:1265779797
Name:JONES, WILLIE MARK IV (MBA, RRT, RCP, CFTS)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:MARK
Last Name:JONES
Suffix:IV
Gender:M
Credentials:MBA, RRT, RCP, CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SMITH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-4911
Mailing Address - Country:US
Mailing Address - Phone:252-532-2582
Mailing Address - Fax:252-410-0743
Practice Address - Street 1:312 ACADEMY ST S
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3200
Practice Address - Country:US
Practice Address - Phone:252-532-2582
Practice Address - Fax:252-519-1180
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFTS1590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist