Provider Demographics
NPI:1861201337
Name:JADE, TAYLA
Entity type:Individual
Prefix:
First Name:TAYLA
Middle Name:
Last Name:JADE
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:PO BOX 1666
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-1666
Mailing Address - Country:US
Mailing Address - Phone:573-336-1970
Mailing Address - Fax:573-365-7143
Practice Address - Street 1:704 ROUTE 66 W STE 105
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-8322
Practice Address - Country:US
Practice Address - Phone:573-336-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician