Provider Demographics
NPI:1982002101
Name:CORWIN, JAN ROSE (CCC)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:ROSE
Last Name:CORWIN
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SAINT JAMES DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 SAINT JAMES DR
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94611-3622
Practice Address - Country:US
Practice Address - Phone:510-205-3978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5306235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist