Basic Information
| Provider Information | |||||||||
| NPI: | 1124257852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183824600 | ||||||||
| FaxNumber: | 9183823183 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 S HOUSTON AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183824600 | ||||||||
| FaxNumber: | 9183823183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4775 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200262140B | 05 | OK | MEDICAID |