Provider Demographics
NPI:1902946221
Name:JONES, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MAIN ST
Mailing Address - Street 2:P.O. BOX 1123
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1842
Mailing Address - Country:US
Mailing Address - Phone:208-743-8101
Mailing Address - Fax:208-746-7402
Practice Address - Street 1:1020 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1842
Practice Address - Country:US
Practice Address - Phone:208-743-8101
Practice Address - Fax:208-746-7402
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-11201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017772OtherREGENCE BLUE SHIELD
IDL3076OtherBLUE CROSS
IDL3076OtherBLUE CROSS