Basic Information
| Provider Information | |||||||||
| NPI: | 1417030263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | JERROMY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 MOW WAY ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735036300 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 HEALTH CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730996381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057176800 | ||||||||
| FaxNumber: | 4057177964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 67464 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200097480A | 05 | OK | MEDICAID |