Basic Information
| Provider Information | |||||||||
| NPI: | 1255588166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 372 S GREENO RD | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519904243 | ||||||||
| FaxNumber: | 2519280126 | ||||||||
| Practice Location | |||||||||
| Address1: | 372 S GREENO RD | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519904243 | ||||||||
| FaxNumber: | 2519280126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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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 | 1041C0700X | 0873C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 051530538 | 01 | AL | BLUE CROSS/ BLUE SHIELD | OTHER |