Provider Demographics
NPI:1124606140
Name:PROVOST, JANELLE (DC)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JANELLE
Other - Middle Name:
Other - Last Name:SLUGOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:151 MARIANNA WAY
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1801
Mailing Address - Country:US
Mailing Address - Phone:669-770-5904
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD STE M257
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3904
Practice Address - Country:US
Practice Address - Phone:408-502-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2023-11-01
Deactivation Date:2021-12-16
Deactivation Code:
Reactivation Date:2022-02-08
Provider Licenses
StateLicense IDTaxonomies
CA35035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor