Provider Demographics
NPI:1124679410
Name:JONES, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-1130
Practice Address - Country:US
Practice Address - Phone:888-305-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician