Provider Demographics
NPI:1679099303
Name:WHITE, TYLON JADE
Entity type:Individual
Prefix:
First Name:TYLON
Middle Name:JADE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYLON
Other - Middle Name:
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0614
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:990 VILLA ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-1236
Practice Address - Country:US
Practice Address - Phone:270-889-4082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2545311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical