Basic Information
| Provider Information | |||||||||
| NPI: | 1760864417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15481 N JARVIS RD | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640233 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15481 N JARVIS RD | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184565131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.