Basic Information
Provider Information | |||||||||
NPI: | 1265000111 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JONES | ||||||||
FirstName: | BREANNA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JONES | ||||||||
OtherFirstName: | BREANNA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BT | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
Address2: |   | ||||||||
City: | CORAL GABLES | ||||||||
State: | FL | ||||||||
PostalCode: | 331344108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8448541116 | ||||||||
FaxNumber: | 3058469711 | ||||||||
Practice Location | |||||||||
Address1: | 2288 BLUE WATER BLVD STE 310 | ||||||||
Address2: |   | ||||||||
City: | ODENTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211133301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106306936 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2021 | ||||||||
LastUpdateDate: | 06/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   | MD | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 11431442750 | 05 | MD |   | MEDICAID |