Basic Information
| Provider Information | |||||||||
| NPI: | 1356682165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11700 KANIS RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722113729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012211941 | ||||||||
| FaxNumber: | 5012211553 | ||||||||
| Practice Location | |||||||||
| Address1: | 11700 KANIS RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722113729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012211941 | ||||||||
| FaxNumber: | 5012211553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2013 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.