MEDICARE: JADE ELAINE TILLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1831736057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE ELAINE TILLEY

Provider Business Mailing Address
First Line	:	3005 ROSS DRIVE APT V #21
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526
Country	:	US
Telephone Number	:	661-302-3634
Fax Number	:

Provider Business Practice Location Address
First Line	:	3005 ROSS DRIVE APT V #21
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526
Country	:	US
Telephone Number	:	661-302-3634
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2019
Last Update Date	:	12/06/2019

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