Provider Demographics
NPI:1699948083
Name:JONES, JACK EDWARD II
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:EDWARD
Last Name:JONES
Suffix:II
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 1:90 LAKESHORE DR.
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270
Mailing Address - Country:US
Mailing Address - Phone:760-469-3208
Mailing Address - Fax:
Practice Address - Street 1:90 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4054
Practice Address - Country:US
Practice Address - Phone:760-469-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482707171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications