Provider Demographics
NPI:1447685664
Name:RATHJEN, TARA LEA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEA
Last Name:RATHJEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LEA
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:VAN HORNE
Mailing Address - State:IA
Mailing Address - Zip Code:52346-0004
Mailing Address - Country:US
Mailing Address - Phone:319-361-6529
Mailing Address - Fax:319-298-0970
Practice Address - Street 1:2501 S CENTER STREET
Practice Address - Street 2:SUITE M
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158
Practice Address - Country:US
Practice Address - Phone:319-361-6529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0101342Medicaid