Provider Demographics
NPI:1093304149
Name:TATUM, REBECCA JORDAN (LPC, MS)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JORDAN
Last Name:TATUM
Suffix:
Gender:F
Credentials:LPC, MS
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JORDAN
Other - Last Name:CHENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, MS
Mailing Address - Street 1:17422 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2233
Mailing Address - Country:US
Mailing Address - Phone:623-237-2767
Mailing Address - Fax:
Practice Address - Street 1:14301 N 87TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3689
Practice Address - Country:US
Practice Address - Phone:480-788-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-21526101Y00000X
AZ16875101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty