Provider Demographics
NPI:1922632355
Name:JONES MEDINE, TIA DANIELLE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:DANIELLE
Last Name:JONES MEDINE
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 1:12 WEDGEFIELD CT
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-3754
Mailing Address - Country:US
Mailing Address - Phone:302-563-0642
Mailing Address - Fax:
Practice Address - Street 1:12 WEDGEFIELD CT
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-3754
Practice Address - Country:US
Practice Address - Phone:302-563-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00017511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical