Healthcare Provider Details

I. General information

NPI: 1932662855
Provider Name (Legal Business Name): MARY JEAN TIBBETS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SW GAGE BLVD
TOPEKA KS
66622-0001
US

IV. Provider business mailing address

2200 SW GAGE BLVD
TOPEKA KS
66622-0001
US

V. Phone/Fax

Practice location:
  • Phone: 785-350-3111
  • Fax:
Mailing address:
  • Phone: 785-350-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5502
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06545
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: