Provider Demographics
NPI:1922160779
Name:JEAN, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6995 N CARMEL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46160-9487
Mailing Address - Country:US
Mailing Address - Phone:812-597-4198
Mailing Address - Fax:812-597-2465
Practice Address - Street 1:6995 N CARMEL RIDGE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:IN
Practice Address - Zip Code:46160-9487
Practice Address - Country:US
Practice Address - Phone:812-597-4198
Practice Address - Fax:812-597-2465
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN469310174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist