Provider Demographics
NPI:1114407632
Name:WHITEHEAD, TIERNEY SIEVERS (BA)
Entity type:Individual
Prefix:MRS
First Name:TIERNEY
Middle Name:SIEVERS
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:TIERNEY
Other - Middle Name:JO
Other - Last Name:SIEVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:2428 WINCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1086
Mailing Address - Country:US
Mailing Address - Phone:904-993-2554
Mailing Address - Fax:
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator