Provider Demographics
NPI:1841757002
Name:TYSON, JENNIFER DIANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANNE
Last Name:TYSON
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 1:6551 MCKINNEY RANCH PKWY APT 8205
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-4641
Mailing Address - Country:US
Mailing Address - Phone:972-439-6932
Mailing Address - Fax:
Practice Address - Street 1:6551 MCKINNEY RANCH PKWY APT 8205
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-4641
Practice Address - Country:US
Practice Address - Phone:972-439-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-74382106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician