Provider Demographics
NPI:1518297191
Name:GANANN, JAN (PHD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:GANANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2504
Mailing Address - Country:US
Mailing Address - Phone:662-323-9261
Mailing Address - Fax:662-324-9647
Practice Address - Street 1:100 OLD STURGIS RD
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-6600
Practice Address - Country:US
Practice Address - Phone:662-285-6225
Practice Address - Fax:662-285-6226
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS104343103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool