Healthcare Provider Details

I. General information

NPI: 1265777668
Provider Name (Legal Business Name): MRS. JOLANDA CAROL TIBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7568 ROUTE 166
CREAL SPRINGS IL
62922-2700
US

IV. Provider business mailing address

7568 ROUTE 166
CREAL SPRINGS IL
62922-2700
US

V. Phone/Fax

Practice location:
  • Phone: 814-952-6195
  • Fax:
Mailing address:
  • Phone: 814-952-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: