Provider Demographics
NPI:1295282952
Name:JONES, GARY
Entity type:Individual
Prefix:
First Name:GARY
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 1:8901 LAKEHURST DR
Mailing Address - Street 2:SIDE A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5161
Mailing Address - Country:US
Mailing Address - Phone:907-764-8331
Mailing Address - Fax:907-249-7811
Practice Address - Street 1:6700 ROCKRIDGE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-1898
Practice Address - Country:US
Practice Address - Phone:907-764-8331
Practice Address - Fax:907-249-7811
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100619320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities