Provider Demographics
NPI:1881307031
Name:JONES, MIA WHITTAKER (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:WHITTAKER
Last Name:JONES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 WICKER ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6523
Practice Address - Country:US
Practice Address - Phone:919-230-1419
Practice Address - Fax:984-278-6610
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10024470363LP0808X
NC50174412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry