Basic Information
| Provider Information | |||||||||
| NPI: | 1740655901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANIS | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | TASHINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 LEONARD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162845871 | ||||||||
| FaxNumber: | 6167741001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2944 FULLER AVE NE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495053784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162845871 | ||||||||
| FaxNumber: | 6167741001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2015 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.