Provider Demographics
NPI:1275024432
Name:JONS, TYRA LARAE (ATC)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:LARAE
Last Name:JONS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:TYRA
Other - Middle Name:LARAE
Other - Last Name:PATZLAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:12455 US HIGHWAY 16A
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-8357
Mailing Address - Country:US
Mailing Address - Phone:605-770-0390
Mailing Address - Fax:
Practice Address - Street 1:1635 CAREGIVER CIR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8529
Practice Address - Country:US
Practice Address - Phone:605-755-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD05922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD01324319OtherDRIVERS LICENSE