Provider Demographics
NPI:1366513350
Name:JONES, KENNETH DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:JONES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 HARPER ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30824
Mailing Address - Country:US
Mailing Address - Phone:706-774-0404
Mailing Address - Fax:706-774-1562
Practice Address - Street 1:1430 HARPER ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30824
Practice Address - Country:US
Practice Address - Phone:706-774-0404
Practice Address - Fax:706-774-1562
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0091822084P0800X
SC62932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00074621AMedicaid
GA00074621AMedicaid
D40287Medicare UPIN