Provider Demographics
NPI:1467996652
Name:JEAN, LANA
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 HAWTHORNE AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4675
Mailing Address - Country:US
Mailing Address - Phone:503-399-0204
Mailing Address - Fax:
Practice Address - Street 1:752 HAWTHORNE AVE NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4675
Practice Address - Country:US
Practice Address - Phone:503-399-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4116174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist