Provider Demographics
NPI:1164649083
Name:STEWART, JAN (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 HIGHWAY 411
Mailing Address - Street 2:
Mailing Address - City:VONORE
Mailing Address - State:TN
Mailing Address - Zip Code:37885-2455
Mailing Address - Country:US
Mailing Address - Phone:423-884-7271
Mailing Address - Fax:423-884-3277
Practice Address - Street 1:1206 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2455
Practice Address - Country:US
Practice Address - Phone:423-884-7271
Practice Address - Fax:423-881-3277
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW6641041C0700X
TN0005100231041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I801665Medicare PIN