Provider Demographics
NPI:1508552621
Name:JONES, AMANI DIVINE
Entity Type:Individual
Prefix:
First Name:AMANI
Middle Name:DIVINE
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 INNIS DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-6624
Mailing Address - Country:US
Mailing Address - Phone:910-554-9334
Mailing Address - Fax:
Practice Address - Street 1:12200 WARWICK BLVD STE 290
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2344
Practice Address - Country:US
Practice Address - Phone:757-534-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110009604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant