Provider Demographics
NPI:1083919377
Name:WALL, JANE (LMFT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:JOHNSON-WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:2843 S COUNTY TRL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1728
Mailing Address - Country:US
Mailing Address - Phone:401-855-2768
Mailing Address - Fax:
Practice Address - Street 1:2843 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1728
Practice Address - Country:US
Practice Address - Phone:401-855-2768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMFT00133106H00000X
MA1294106H00000X
CAMFC34995106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist