Provider Demographics
NPI:1720185648
Name:STATON, JANA JO (PHD, LCPC)
Entity Type:Individual
Prefix:DR
First Name:JANA
Middle Name:JO
Last Name:STATON
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5919
Mailing Address - Country:US
Mailing Address - Phone:406-543-9491
Mailing Address - Fax:
Practice Address - Street 1:415 N HIGGINS AVE # 112
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4522
Practice Address - Country:US
Practice Address - Phone:406-543-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC 653101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000075498OtherBLUE CROSS/BLUE SHIELD
MT0000250920Medicaid