Provider Demographics
NPI:1285178020
Name:JONES, CODY (BA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 MACKEY PL STE 135
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2528
Mailing Address - Country:US
Mailing Address - Phone:318-220-8423
Mailing Address - Fax:318-220-8573
Practice Address - Street 1:2715 MACKEY PL STE 135
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2528
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:318-220-8573
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1003279654Medicaid