Provider Demographics
NPI:1952795973
Name:JONES, PREMALA (PHD)
Entity type:Individual
Prefix:
First Name:PREMALA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
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:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:PENINSULA
Mailing Address - State:OH
Mailing Address - Zip Code:44264-0064
Mailing Address - Country:US
Mailing Address - Phone:330-347-3717
Mailing Address - Fax:
Practice Address - Street 1:4198 PINE DR
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9299
Practice Address - Country:US
Practice Address - Phone:330-347-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7263103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist