Provider Demographics
NPI:1154841153
Name:TARVER, JILLISA CLOBREE
Entity type:Individual
Prefix:
First Name:JILLISA
Middle Name:CLOBREE
Last Name:TARVER
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 1:100 MYRTLE ST APT 336
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5431
Mailing Address - Country:US
Mailing Address - Phone:863-307-1290
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:863-307-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 247200000X
1-20-43766103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106312600Medicaid