Provider Demographics
NPI:1417662909
Name:THIBODEAU, JANE (LMFTA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1216
Mailing Address - Country:US
Mailing Address - Phone:919-452-6715
Mailing Address - Fax:
Practice Address - Street 1:128 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1216
Practice Address - Country:US
Practice Address - Phone:919-452-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12494A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist