Provider Demographics
NPI:1952039810
Name:JONES, REGINALD ALEXIS
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:ALEXIS
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 1:303 W KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:MEDICINE LODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67104-1438
Mailing Address - Country:US
Mailing Address - Phone:620-409-0095
Mailing Address - Fax:
Practice Address - Street 1:303 W KANSAS AVE
Practice Address - Street 2:
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104-1438
Practice Address - Country:US
Practice Address - Phone:620-409-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK04308568172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty