Basic Information
| Provider Information | |||||||||
| NPI: | 1073595880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIPPIN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
| FaxNumber: | 8884686603 | ||||||||
| Practice Location | |||||||||
| Address1: | 768 TAYLOR RD | ||||||||
| Address2: | |||||||||
| City: | KALAMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD2019-0927 | NM | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 23642 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 00022815 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 37261 | 01 | IA | WELLMARK BCBS | OTHER | 0196147 | 05 | IA | MEDICAID | MD2019-0927 | 01 | NM | NEW MEXICO MEDICAL BOARD | OTHER |