Provider Demographics
NPI:1912496373
Name:TANNER, JORDAN MICHAEL (QMHP, PEL, MS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:TANNER
Suffix:
Gender:M
Credentials:QMHP, PEL, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3491 N 1300TH ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:IL
Mailing Address - Zip Code:62443-2826
Mailing Address - Country:US
Mailing Address - Phone:618-534-1801
Mailing Address - Fax:
Practice Address - Street 1:1901 S 4TH ST STE 213
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4188
Practice Address - Country:US
Practice Address - Phone:217-347-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health