=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295092310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONES PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 SUPERIOR ST STE A
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-966-1972
-----------------------------------------------------
Fax | 810-966-1973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 SUPERIOR ST STE A
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-966-1972
-----------------------------------------------------
Fax | 810-966-1973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK STEPHEN JONES
-----------------------------------------------------
Credential | LLP
-----------------------------------------------------
Telephone | 810-966-1972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4301051834
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301011246
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------