Basic Information
| Provider Information | |||||||||
| NPI: | 1821248535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCMFT, LCAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 N WOODLAWN ST STE 102 | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166522590 | ||||||||
| FaxNumber: | 3166522595 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N WOODLAWN ST STE 102 | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166522590 | ||||||||
| FaxNumber: | 3166522595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 566 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 828 | KS | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200576810A | 05 | KS | MEDICAID |