Provider Demographics
NPI:1043838402
Name:HERMANN, JAN (CLMT)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:HERMANN
Suffix:
Gender:M
Credentials:CLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9036 ARCADIA AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-1454
Mailing Address - Country:US
Mailing Address - Phone:626-616-2542
Mailing Address - Fax:
Practice Address - Street 1:1450 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2387
Practice Address - Country:US
Practice Address - Phone:626-798-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79049OtherSTATE LICENSE NUMBER