Provider Demographics
NPI:1902008964
Name:LOPER, JAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:
Last Name:LOPER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 CREE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1619 CURLEW DR
Practice Address - Street 2:SUITE 5
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4719
Practice Address - Country:US
Practice Address - Phone:208-535-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1564235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist