Provider Demographics
NPI:1265674709
Name:TATUM, JOLYN INEZ (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOLYN
Middle Name:INEZ
Last Name:TATUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 2022
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96264-2022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8TH MEDICAL GROUP
Practice Address - Street 2:UNIT 2022
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96264-2022
Practice Address - Country:US
Practice Address - Phone:315-782-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000907103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth