Provider Demographics
NPI:1376843383
Name:JONES, STACEY MARIE (LPN)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MARIE
Last Name:JONES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 NW 7TH ST
Mailing Address - Street 2:PO BOX 1938
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-1506
Mailing Address - Country:US
Mailing Address - Phone:541-240-1603
Mailing Address - Fax:
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-0160
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP0055060164W00000X
OR200730406LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1741037Medicaid