Provider Demographics
NPI:1669205936
Name:JOHNS, TYLER JENNINGS
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JENNINGS
Last Name:JOHNS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3370
Mailing Address - Country:US
Mailing Address - Phone:616-594-7135
Mailing Address - Fax:
Practice Address - Street 1:96 W 15TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3370
Practice Address - Country:US
Practice Address - Phone:616-594-7135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851118228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health