Provider Demographics
NPI:1114231339
Name:BARDOU, JANE ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ANN
Last Name:BARDOU
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6686 STYERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8074
Mailing Address - Country:US
Mailing Address - Phone:336-750-0130
Mailing Address - Fax:336-750-0073
Practice Address - Street 1:526 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3736
Practice Address - Country:US
Practice Address - Phone:336-750-0130
Practice Address - Fax:336-750-0073
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2014-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7761101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional