=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588965321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J A JONES OD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2010
-----------------------------------------------------
Last Update Date | 12/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 W BROADWAY STE. 101
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-0499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-447-2009
-----------------------------------------------------
Fax | 573-447-2017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 W BROADWAY STE. 101
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-0499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-447-2009
-----------------------------------------------------
Fax | 573-447-2017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. J A JONES
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 573-447-2009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MO TO 3025
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------