Healthcare Provider Details

I. General information

NPI: 1780235580
Provider Name (Legal Business Name): MATTHEW MICHAEL DOUGLAS JONES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 LORRAINE PATH
SAINT JOSEPH MI
49085-8630
US

IV. Provider business mailing address

2627 BOTHAM CT
SAINT JOSEPH MI
49085-1917
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-1111
  • Fax:
Mailing address:
  • Phone: 269-449-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004072
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: