Provider Demographics
NPI:1285136382
Name:JONES, MALLORY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 ESPLANADE DR STE B
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5500
Mailing Address - Country:US
Mailing Address - Phone:847-458-7546
Mailing Address - Fax:224-333-3436
Practice Address - Street 1:2430 ESPLANADE DR STE B
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5500
Practice Address - Country:US
Practice Address - Phone:847-458-7546
Practice Address - Fax:224-333-3436
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.006519OtherIL LICENSE