Provider Demographics
NPI:1740334226
Name:KING, JAN GOODWIN (LCSW)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:GOODWIN
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:A-200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8666
Mailing Address - Country:US
Mailing Address - Phone:512-241-0405
Mailing Address - Fax:512-241-2833
Practice Address - Street 1:4005 SPICEWOOD SPRINGS RD
Practice Address - Street 2:A-200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8666
Practice Address - Country:US
Practice Address - Phone:512-241-0405
Practice Address - Fax:512-241-2833
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX610002Medicare ID - Type Unspecified