Provider Demographics
NPI:1427390830
Name:MICHAEL, JAN (LICSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 W GRANDRIDGE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1678
Mailing Address - Country:US
Mailing Address - Phone:509-851-3280
Mailing Address - Fax:509-349-5069
Practice Address - Street 1:6304 W RICHARDSON RD
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-1911
Practice Address - Country:US
Practice Address - Phone:509-851-3280
Practice Address - Fax:509-349-5069
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-23
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605499281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE