Provider Demographics
NPI:1073595880
Name:TIPPIN, JON M (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:TIPPIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:888-468-6603
Practice Address - Street 1:768 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:KALAMA
Practice Address - State:WA
Practice Address - Zip Code:98625
Practice Address - Country:US
Practice Address - Phone:615-345-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-09272084N0400X
IA236422084N0400X
WA000228152084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA37261OtherWELLMARK BCBS
IA0196147Medicaid
NMMD2019-0927OtherNEW MEXICO MEDICAL BOARD
IA37261OtherWELLMARK BCBS
A07411Medicare UPIN