Provider Demographics
NPI:1174190094
Name:JONES, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 TERROSA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0074
Mailing Address - Country:US
Mailing Address - Phone:870-718-6543
Mailing Address - Fax:
Practice Address - Street 1:1919 S SHILOH RD STE 400
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-8211
Practice Address - Country:US
Practice Address - Phone:469-320-1267
Practice Address - Fax:945-242-8020
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14507363A00000X
AZ10732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA14507OtherPA LICENSE