=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265135131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMMIE LEE JONES JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2023
-----------------------------------------------------
Last Update Date | 03/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 489 FERN ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72360-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-821-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 489 FERN ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72360-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-821-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 900081272
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 900081272
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------