Provider Demographics
NPI:1457335820
Name:BACON, JAN GARVER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:GARVER
Last Name:BACON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9125 BRIDGEPORT WAY SW STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2448
Mailing Address - Country:US
Mailing Address - Phone:253-254-8284
Mailing Address - Fax:253-276-0082
Practice Address - Street 1:9125 BRIDGEPORT WAY SW STE 102
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2448
Practice Address - Country:US
Practice Address - Phone:253-254-8284
Practice Address - Fax:253-276-0082
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001639103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical