Basic Information
| Provider Information | |||||||||
| NPI: | 1992063697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TJARKS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2349 W NOTTINGHAM ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658102298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177613210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2135 S FREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178207990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X | 2009024749 | MO | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
ID Information
| ID | Type | State | Issuer | Description | 020602071 | 01 | NATIONAL ATHLETIC TRAINERS ASSOCIATION BOARD OF CERTIFICATION NUMBER | OTHER | 2009024749 | 01 | MO | MISSOURI STATE BOARD OF LICENSER | OTHER |