1538204284 NPI number — WYLANTA RENE JONES SLP

Table of content: WYLANTA RENE JONES SLP (NPI 1538204284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538204284 NPI number — WYLANTA RENE JONES SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONES
Provider First Name:
WYLANTA
Provider Middle Name:
RENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTS
Provider Other First Name:
WYLANTA
Provider Other Middle Name:
RENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538204284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14050 S HWY 69
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAYER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-326-2150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HUMBOLDT UNIFIED SCHOOL DISTRICT #22 SPECIAL SRVCS OFIC
Provider Second Line Business Practice Location Address:
8766 EAST HWY 69
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-759-4028
Provider Business Practice Location Address Fax Number:
928-759-4030
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP2190 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 759277 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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