Provider Demographics
NPI:1578736757
Name:DEJACK, TOVA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TOVA
Middle Name:
Last Name:DEJACK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 KAMERIN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-7840
Mailing Address - Country:US
Mailing Address - Phone:541-324-4617
Mailing Address - Fax:
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-324-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid