1053947945 NPI number — MS. TYEASA RENAE JONES PMHNP-BC

Table of content: MS. LIANNA THOMAS COTA-L (NPI 1417657909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053947945 NPI number — MS. TYEASA RENAE JONES PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONES
Provider First Name:
TYEASA
Provider Middle Name:
RENAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053947945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41704 W SMITH ENKE RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARICOPA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85138-2710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41704 W SMITH ENKE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARICOPA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85138-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-200-3526
Provider Business Practice Location Address Fax Number:
623-401-6598
Provider Enumeration Date:
03/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  202202599NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 238907 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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