Provider Demographics
NPI:1629379938
Name:SCOUTEN, JAN HAROLD (MDIV)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:HAROLD
Last Name:SCOUTEN
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5062 N 19TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3225
Mailing Address - Country:US
Mailing Address - Phone:623-939-6567
Mailing Address - Fax:
Practice Address - Street 1:5062 N 19TH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3225
Practice Address - Country:US
Practice Address - Phone:623-939-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISCAC-1653101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)