Provider Demographics
NPI:1992063697
Name:TJARKS, JEREMY RAY (MS, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:RAY
Last Name:TJARKS
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 W NOTTINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2298
Mailing Address - Country:US
Mailing Address - Phone:417-761-3210
Mailing Address - Fax:
Practice Address - Street 1:2135 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009024749246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
020602071OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION BOARD OF CERTIFICATION NUMBER
MO2009024749OtherMISSOURI STATE BOARD OF LICENSER