Basic Information
| Provider Information | |||||||||
| NPI: | 1952675381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | MOODY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | NP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 EAST ST | ||||||||
| Address2: | |||||||||
| City: | CLARENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634371902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606992124 | ||||||||
| FaxNumber: | 6606993534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 2012006982 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 2013028349 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2013028349 | 01 | MO | STATE LICENSE | OTHER |