1760410146 NPI number — DR. KECIA JACKSON JONES M.D.

Table of content: DR. KECIA JACKSON JONES M.D. (NPI 1760410146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760410146 NPI number — DR. KECIA JACKSON JONES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONES
Provider First Name:
KECIA
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
KECIA
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760410146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMOREST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-754-1034
Provider Business Mailing Address Fax Number:
706-754-1032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 ADAMS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
DEMOREST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-754-1034
Provider Business Practice Location Address Fax Number:
706-754-1032
Provider Enumeration Date:
06/28/2006

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: 207R00000X , with the licence number:  055247 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 620650772A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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