Provider Demographics
NPI:1699449652
Name:BALLARD, JANICE
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:
Last Name:BALLARD
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 1:55 KLEER VU DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-2165
Mailing Address - Country:US
Mailing Address - Phone:901-338-2678
Mailing Address - Fax:731-326-5081
Practice Address - Street 1:55 KLEER VU DR
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-2165
Practice Address - Country:US
Practice Address - Phone:901-338-2678
Practice Address - Fax:731-326-5081
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000020690320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities