Provider Demographics
NPI:1619339637
Name:JONES, DIETRA
Entity type:Individual
Prefix:
First Name:DIETRA
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 1:613 HAMRICK AVE
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-1624
Mailing Address - Country:US
Mailing Address - Phone:815-666-5817
Mailing Address - Fax:
Practice Address - Street 1:613 HAMRICK AVE
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1624
Practice Address - Country:US
Practice Address - Phone:815-666-5817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver