Provider Demographics
NPI:1225362627
Name:STANLEY, JAN PHILIP (MSSW)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:PHILIP
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#1 TANO ESCONDIDO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506
Mailing Address - Country:US
Mailing Address - Phone:505-983-2277
Mailing Address - Fax:505-476-2320
Practice Address - Street 1:1 TANO ESCONDIDO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-7512
Practice Address - Country:US
Practice Address - Phone:505-983-2277
Practice Address - Fax:505-476-2320
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-19271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical