Provider Demographics
NPI:1104034081
Name:JONES, MICHAEL EDWARD (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:JONES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 ASHLEY RIDGE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7231
Mailing Address - Country:US
Mailing Address - Phone:318-671-8772
Mailing Address - Fax:318-671-8776
Practice Address - Street 1:463 ASHLEY RIDGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7231
Practice Address - Country:US
Practice Address - Phone:318-671-8772
Practice Address - Fax:318-671-8776
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA01597OtherSTATE LICENSE