Provider Demographics
NPI:1649311002
Name:MEAD, JAN M (PT)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:M
Last Name:MEAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:M
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6930 OAK VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1513
Mailing Address - Country:US
Mailing Address - Phone:719-332-4580
Mailing Address - Fax:
Practice Address - Street 1:5747 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3684
Practice Address - Country:US
Practice Address - Phone:541-575-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5427225100000X
CO7825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80459820Medicaid
CO80459820Medicaid