Healthcare Provider Details

I. General information

NPI: 1508256090
Provider Name (Legal Business Name): KEVIN JONES I LICDC-CS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 W ELM ST
LIMA OH
45805-3236
US

IV. Provider business mailing address

1213 W ELM ST
LIMA OH
45805-3236
US

V. Phone/Fax

Practice location:
  • Phone: 419-224-4392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number913123
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: