Provider Demographics
NPI:1518558790
Name:JEAN, TAHESHA A
Entity Type:Individual
Prefix:
First Name:TAHESHA
Middle Name:A
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 NEW PITTSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-6207
Mailing Address - Country:US
Mailing Address - Phone:917-678-7289
Mailing Address - Fax:
Practice Address - Street 1:507 NEW PITTSBURG AVE
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-6207
Practice Address - Country:US
Practice Address - Phone:917-678-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician