Provider Demographics
NPI:1316712300
Name:JONES, JOHN W
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:JONES
Suffix:
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 1:6849 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2231
Mailing Address - Country:US
Mailing Address - Phone:312-636-6912
Mailing Address - Fax:
Practice Address - Street 1:6849 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2231
Practice Address - Country:US
Practice Address - Phone:312-636-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical