Provider Demographics
NPI:1366707168
Name:JONES, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17916 BONSTELLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3478
Mailing Address - Country:US
Mailing Address - Phone:313-629-6800
Mailing Address - Fax:
Practice Address - Street 1:17916 BONSTELLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3478
Practice Address - Country:US
Practice Address - Phone:313-629-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ520414178589172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver