Healthcare Provider Details

I. General information

NPI: 1083351019
Provider Name (Legal Business Name): MS. SHAVON L JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4762 LOST COLONY CT
STONE MOUNTAIN GA
30088-3522
US

IV. Provider business mailing address

4762 LOST COLONY CT
STONE MOUNTAIN GA
30088-3522
US

V. Phone/Fax

Practice location:
  • Phone: 267-370-6972
  • Fax: 404-994-7006
Mailing address:
  • Phone: 267-370-6972
  • Fax: 404-994-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: