Basic Information
| Provider Information | |||||||||
| NPI: | 1720127830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | E | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647351192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608855511 | ||||||||
| FaxNumber: | 6608858496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 NORTH SECOND ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647351192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608855511 | ||||||||
| FaxNumber: | 6608858496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 18543 | MS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | R2E22 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 242050557 | 05 | MO | MEDICAID |