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General NPI Number Information
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NPI Number | 1336565035
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Entity Type | Individual
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Provider Name | TANITA MARTIN-THAMES LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/05/2014
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Last Update Date | 12/05/2018
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Provider Practice Location Address
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Address Line | 2637 RIDGEWOOD RD STE G
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City | JACKSON
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State | MS
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Zip | 39216-4971
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Country | US
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Telephone | 913-915-6236
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2358
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City | CLINTON
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State | MS
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Zip | 39060-2358
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Country | US
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Telephone | 913-915-6236
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C7489
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License Number State | MS
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