Healthcare Provider Details

I. General information

NPI: 1720579428
Provider Name (Legal Business Name): MS. DESTINEE JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 09/29/2026
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 W HEBBLE AVE
FAIRBORN OH
45324-4960
US

IV. Provider business mailing address

PO BOX 55
WALTON KY
41094-0055
US

V. Phone/Fax

Practice location:
  • Phone: 937-479-7290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: