Provider Demographics
NPI:1508930314
Name:SMITH, JAN LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:BOYNTON HEALTH SERVICE-UNIVERSITY OF MINNESOTA
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0340
Mailing Address - Country:US
Mailing Address - Phone:612-624-1444
Mailing Address - Fax:
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:BOYNTON HEALTH SERVICE-UNIVERSITY OF MINNESOTA
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0340
Practice Address - Country:US
Practice Address - Phone:612-624-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical