Provider Demographics
NPI:1992913701
Name:JECKOVICH, TANYA M (LCSW)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:JECKOVICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:M
Other - Last Name:SCHREINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2449 21ST ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-3809
Mailing Address - Country:US
Mailing Address - Phone:717-861-0701
Mailing Address - Fax:270-574-6443
Practice Address - Street 1:2449 21ST ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-3809
Practice Address - Country:US
Practice Address - Phone:717-861-0701
Practice Address - Fax:270-574-6443
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074598-11041C0700X
FLSW102561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty