Basic Information
| Provider Information | |||||||||
| NPI: | 1790108942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | QUINTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E MAIN | ||||||||
| Address2: | RESOURCE MANAGEMENT | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367211 | ||||||||
| FaxNumber: | 5802725757 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 ARROWHEAD DRIVE | ||||||||
| Address2: | ADOLESCENT TRANSITIONAL LIVING CENTER | ||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053312300 | ||||||||
| FaxNumber: | 4053312302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2014 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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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 | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1588968275 | 05 | OK | MEDICAID |