Provider Demographics
NPI:1871673954
Name:FOSSUM, JANET LOUISE (PHD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:LOUISE
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:PHD
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 54739
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0739
Mailing Address - Country:US
Mailing Address - Phone:714-456-5902
Mailing Address - Fax:714-456-5112
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:BLDG 3, ROUTE 81
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-5902
Practice Address - Fax:714-456-5112
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WCP18740AMedicare ID - Type Unspecified