Provider Demographics
NPI:1902468259
Name:JONES, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17753 W ELGER CT
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53146-1807
Mailing Address - Country:US
Mailing Address - Phone:414-659-2525
Mailing Address - Fax:
Practice Address - Street 1:8989 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-3803
Practice Address - Country:US
Practice Address - Phone:414-216-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19898-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist