Provider Demographics
NPI:1043214679
Name:WARNER, JAN EARL (PHD HSPP)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:EARL
Last Name:WARNER
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:EARL
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, HSPP
Mailing Address - Street 1:230 E DAY RD
Mailing Address - Street 2:#160
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3463
Mailing Address - Country:US
Mailing Address - Phone:574-271-8222
Mailing Address - Fax:574-271-8896
Practice Address - Street 1:230 E DAY RD STE 160
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3463
Practice Address - Country:US
Practice Address - Phone:574-271-8222
Practice Address - Fax:574-271-8896
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ20040740103G00000X
IN20040740A103G00000X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100383350AMedicaid
IN000000196536OtherBLUE CROSS BLUE SHIELD
IN000000196536OtherBLUE CROSS BLUE SHIELD