Provider Demographics
NPI:1912906215
Name:JONES, DICK D (PHD)
Entity Type:Individual
Prefix:DR
First Name:DICK
Middle Name:D
Last Name:JONES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:#330
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:651-642-9255
Mailing Address - Fax:651-642-1506
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:#330
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-642-9255
Practice Address - Fax:651-642-1506
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP-0361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
45696OtherHP
MN412247000Medicaid
11611OtherUCARE
680000545Medicare ID - Type Unspecified
R68543Medicare UPIN