Provider Demographics
NPI:1720455124
Name:JONES, NICHOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLE
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 1:205 TROPHY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-8490
Mailing Address - Country:US
Mailing Address - Phone:239-340-3969
Mailing Address - Fax:
Practice Address - Street 1:55 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7327
Practice Address - Country:US
Practice Address - Phone:910-219-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320724363AS0400X
WI3518-23363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical