Provider Demographics
NPI:1003611757
Name:BALLARD, TAWANNA R
Entity type:Individual
Prefix:
First Name:TAWANNA
Middle Name:R
Last Name:BALLARD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HUGHES LOOP
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-5503
Mailing Address - Country:US
Mailing Address - Phone:731-445-2061
Mailing Address - Fax:
Practice Address - Street 1:39 MURRAY GUARD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3610
Practice Address - Country:US
Practice Address - Phone:731-736-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8403104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker