Provider Demographics
NPI:1053428771
Name:JONES, THERESA ELLEN (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ELLEN
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 DE PAUL DR STE 360
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2513
Mailing Address - Country:US
Mailing Address - Phone:314-739-9293
Mailing Address - Fax:314-739-3968
Practice Address - Street 1:12255 DE PAUL DR STE 360
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2513
Practice Address - Country:US
Practice Address - Phone:314-739-9293
Practice Address - Fax:314-739-3968
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207538109Medicaid
MO207538109Medicaid