Healthcare Provider Details

I. General information

NPI: 1760646731
Provider Name (Legal Business Name): CHAD ALLEN JONES RT(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 SAINT JOE CENTER RD
FORT WAYNE IN
46835-2135
US

IV. Provider business mailing address

3614 SAINT JOE CENTER RD
FORT WAYNE IN
46835-2135
US

V. Phone/Fax

Practice location:
  • Phone: 260-312-0438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberXT016407
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number10-121-12290
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: