Provider Demographics
NPI:1962801936
Name:JONES, AGATHA
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 SEFFNER VALRICO RD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-6159
Mailing Address - Country:US
Mailing Address - Phone:813-651-9532
Mailing Address - Fax:
Practice Address - Street 1:1306 SEFFNER VALRICO RD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-6159
Practice Address - Country:US
Practice Address - Phone:813-651-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL141487900251E00000X
FL2920251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL745223349Medicaid