Provider Demographics
NPI:1558309740
Name:WEBER, JAN L (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:WEBER
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 LYNDALE AVE S STE 179
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5687
Mailing Address - Country:US
Mailing Address - Phone:952-380-8515
Mailing Address - Fax:
Practice Address - Street 1:10800 LYNDALE AVE S STE 179
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-5687
Practice Address - Country:US
Practice Address - Phone:952-380-8515
Practice Address - Fax:952-314-1356
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical