Provider Demographics
NPI:1083774343
Name:KEARNY, JAN E (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:E
Last Name:KEARNY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3150
Mailing Address - Country:US
Mailing Address - Phone:408-293-4489
Mailing Address - Fax:408-293-6188
Practice Address - Street 1:1040 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3150
Practice Address - Country:US
Practice Address - Phone:408-293-4489
Practice Address - Fax:408-293-6188
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77-0010113OtherEIN (PRIVATE NON-PROFIT)
CAPENDINGMedicare ID - Type UnspecifiedAGENCY MEDICARE # (PENDIN