Provider Demographics
NPI:1629005681
Name:CAVANAUGH, JAN STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:STEPHEN
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:4715 VIEWRIDGE AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1680
Mailing Address - Country:US
Mailing Address - Phone:800-257-8715
Mailing Address - Fax:800-819-1655
Practice Address - Street 1:840 S BROOM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4245
Practice Address - Country:US
Practice Address - Phone:800-819-1655
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEB1-0000713103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical