Healthcare Provider Details

I. General information

NPI: 1770543985
Provider Name (Legal Business Name): KENNETH W JONES M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 EDGEWOOD AVE W
JACKSONVILLE FL
32208-6403
US

IV. Provider business mailing address

1004 EDGEWOOD AVE W
JACKSONVILLE FL
32208-6403
US

V. Phone/Fax

Practice location:
  • Phone: 904-765-7774
  • Fax: 904-766-1264
Mailing address:
  • Phone: 904-765-7774
  • Fax: 904-766-1264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0040992
License Number StateFL

VIII. Authorized Official

Name: KENNETH W JONES
Title or Position: PRESIDENT
Credential: M D
Phone: 904-765-7774