Provider Demographics
NPI:1508375973
Name:TATE, JAN MALLORY (LCSW, MED, CSOTP)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MALLORY
Last Name:TATE
Suffix:
Gender:F
Credentials:LCSW, MED, CSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 PEMBERTON ST
Mailing Address - Street 2:
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379-8008
Mailing Address - Country:US
Mailing Address - Phone:917-773-8283
Mailing Address - Fax:
Practice Address - Street 1:105 E CENTER ST STE B-7
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-2420
Practice Address - Country:US
Practice Address - Phone:917-773-8283
Practice Address - Fax:919-551-8711
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC012511101YM0800X, 1041C0700X
NCP0113131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC012511OtherLCSW LICENSE NUMBER