Provider Demographics
NPI:1619329513
Name:TYNAN, JACQUELIN WENTWORTH
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:WENTWORTH
Last Name:TYNAN
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 1:11 EVENING STAR DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-3500
Mailing Address - Country:US
Mailing Address - Phone:413-210-6553
Mailing Address - Fax:
Practice Address - Street 1:258 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2653
Practice Address - Country:US
Practice Address - Phone:413-532-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker