Provider Demographics
NPI:1992404024
Name:JONES, MARY KATHRYN (IS, BI)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:JONES
Suffix:
Gender:F
Credentials:IS, BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 ELIZABETH CIR APT 3
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5780
Mailing Address - Country:US
Mailing Address - Phone:208-241-2772
Mailing Address - Fax:
Practice Address - Street 1:1440 ELIZABETH CIR APT 3
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5780
Practice Address - Country:US
Practice Address - Phone:208-241-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID020701Medicaid