Provider Demographics
NPI:1619092889
Name:VANSLYKE, JAN (MED)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:VANSLYKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 ARTHUR ST
Mailing Address - Street 2:STE. D
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-3778
Mailing Address - Country:US
Mailing Address - Phone:208-454-1576
Mailing Address - Fax:208-454-9863
Practice Address - Street 1:510 ARTHUR ST
Practice Address - Street 2:STE. D
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3778
Practice Address - Country:US
Practice Address - Phone:208-454-1576
Practice Address - Fax:208-454-9863
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-84101YP2500X
IDLMFT-2627106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist