Provider Demographics
NPI:1578921540
Name:KLEIN-JACKSON, TONYA
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:KLEIN-JACKSON
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 1:2910 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1032
Mailing Address - Country:US
Mailing Address - Phone:304-794-9724
Mailing Address - Fax:
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-8801
Practice Address - Country:US
Practice Address - Phone:740-968-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 1000489101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health