Provider Demographics
NPI:1063255693
Name:JONES, GLENN TYRONE (PHD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:TYRONE
Last Name:JONES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 CLAIREMONT DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6463
Mailing Address - Country:US
Mailing Address - Phone:747-998-8343
Mailing Address - Fax:
Practice Address - Street 1:3511 CAMINO DEL RIO S STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4018
Practice Address - Country:US
Practice Address - Phone:888-688-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical