Provider Demographics
NPI:1871296988
Name:SULLIVAN, JAKARA TANAE
Entity type:Individual
Prefix:
First Name:JAKARA
Middle Name:TANAE
Last Name:SULLIVAN
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 1:3214 BRASSFIELD RD APT 1211
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9451
Mailing Address - Country:US
Mailing Address - Phone:336-662-2844
Mailing Address - Fax:
Practice Address - Street 1:3214 BRASSFIELD RD APT 1211
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9451
Practice Address - Country:US
Practice Address - Phone:336-662-2844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician