Provider Demographics
NPI:1356365506
Name:JONES, JACK D JR (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:JONES
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PORTLAND ST STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7390
Mailing Address - Country:US
Mailing Address - Phone:573-886-4600
Mailing Address - Fax:573-886-4695
Practice Address - Street 1:300 PORTLAND ST STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7390
Practice Address - Country:US
Practice Address - Phone:573-886-4600
Practice Address - Fax:573-886-4695
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006029248291U00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO109840003Medicaid