Provider Demographics
NPI:1134790132
Name:JONES, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 LAKELAND DR APT 21G
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9731
Mailing Address - Country:US
Mailing Address - Phone:601-665-6806
Mailing Address - Fax:
Practice Address - Street 1:4701 LAKELAND DR APT 21G
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9731
Practice Address - Country:US
Practice Address - Phone:601-665-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800879553172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver