Provider Demographics
NPI:1386853349
Name:PERRY, JAN ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:ELLEN
Last Name:PERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 PRIMROSE RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010
Mailing Address - Country:US
Mailing Address - Phone:650-375-0543
Mailing Address - Fax:
Practice Address - Street 1:405 PRIMROSE RD
Practice Address - Street 2:SUITE 307
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010
Practice Address - Country:US
Practice Address - Phone:650-375-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS91891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ7007ZMedicare ID - Type Unspecified