Provider Demographics
NPI:1366824096
Name:ANDERSON, JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:FAGAIMA ROAD
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-0552
Mailing Address - Country:US
Mailing Address - Phone:684-252-7455
Mailing Address - Fax:
Practice Address - Street 1:552 FAGAIMA ROAD
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799
Practice Address - Country:US
Practice Address - Phone:684-252-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS4047-A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS4047-AOtherHEALTH REGULATORY BOARD LICENSE