=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447771787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADE JONES APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2017
-----------------------------------------------------
Last Update Date | 06/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3805 E MAIN ST STE J
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-2487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-646-5200
-----------------------------------------------------
Fax | 630-377-3762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1957 EUCLID AVE APT 112
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-466-1956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 209016107
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------