Provider Demographics
NPI:1588957922
Name:JONES, JACK (MPT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724557
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-1557
Mailing Address - Country:US
Mailing Address - Phone:334-625-5795
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:30 S NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-6231
Practice Address - Country:US
Practice Address - Phone:224-218-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013499225100000X
FLPT24581225100000X
IL070.020293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL13636970OtherCAQH
IL13636970OtherCAQH