Basic Information
| Provider Information | |||||||||
| NPI: | 1932419611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES-TARTAGLIA | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 725 MASON ST. | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
| FaxNumber: | 8102573785 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 MACKIN RD. | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
| FaxNumber: | 8102570713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 10/15/2010 | ||||||||
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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 | 1041C0700X | 6801078018 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 386004849 | 05 | MI | MEDICAID |