Provider Demographics
NPI:1366568735
Name:JONES, LARA BETH (MPT)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:BETH
Last Name:JONES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 SHELBY 226
Mailing Address - Street 2:
Mailing Address - City:LEONARD
Mailing Address - State:MO
Mailing Address - Zip Code:63451-2423
Mailing Address - Country:US
Mailing Address - Phone:660-762-4630
Mailing Address - Fax:
Practice Address - Street 1:2005 N. MISSOURI ST.
Practice Address - Street 2:SUITE D.
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-0381
Practice Address - Country:US
Practice Address - Phone:660-385-6540
Practice Address - Fax:660-385-6542
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003025139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001817Medicare ID - Type Unspecified