Basic Information
| Provider Information | |||||||||
| NPI: | 1093055402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 HAMACHER ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622981592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189394200 | ||||||||
| FaxNumber: | 6189394256 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 HAMACHER ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622981592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189394200 | ||||||||
| FaxNumber: | 6189394256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2013004685 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 209013655 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.