Provider Demographics
NPI:1619153905
Name:LONDON, JANUETTE
Entity Type:Individual
Prefix:
First Name:JANUETTE
Middle Name:
Last Name:LONDON
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:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:JUDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75660-0196
Mailing Address - Country:US
Mailing Address - Phone:903-220-8481
Mailing Address - Fax:309-758-1836
Practice Address - Street 1:501 E YOUNG ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-1829
Practice Address - Country:US
Practice Address - Phone:903-220-8481
Practice Address - Fax:903-758-1836
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities