Basic Information
| Provider Information | |||||||||
| NPI: | 1891377248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3075 COUNTY ROAD 18 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467939578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193070651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4180 SAGE BLUFF CROSSING | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604437300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06005181A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.