Provider Demographics
NPI:1154890655
Name:JONES, CHARLES GLENN SR
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GLENN
Last Name:JONES
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 WIER RD APT 9
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3890
Mailing Address - Country:US
Mailing Address - Phone:951-536-4534
Mailing Address - Fax:
Practice Address - Street 1:2026 W BEACON AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-4406
Practice Address - Country:US
Practice Address - Phone:657-276-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)