MEDICARE: MS. A JEAN TANNER LCSW

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	1041C0700X	Clinical Social Worker	KY 411	KY

General Provider Information

NPI Number	:	1093173478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. A JEAN TANNER LCSW

Provider Business Mailing Address
First Line	:	161 SAINT MATTHEWS AVE
Second Line	:	SUITE 18
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3145
Country	:	US
Telephone Number	:	502-930-1113
Fax Number	:	502-290-6800

Provider Business Practice Location Address
First Line	:	161 SAINT MATTHEWS AVE
Second Line	:	SUITE 18
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3145
Country	:	US
Telephone Number	:	502-930-1113
Fax Number	:	502-290-6800

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

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	02/01/2016

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