Provider Demographics
NPI:1750416368
Name:CHAMPION, JAN (LMSW, ACSW)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 KNOWLES ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2767
Mailing Address - Country:US
Mailing Address - Phone:248-542-3446
Mailing Address - Fax:248-589-1765
Practice Address - Street 1:217 KNOWLES ST
Practice Address - Street 2:SUITE 140
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2767
Practice Address - Country:US
Practice Address - Phone:248-542-3446
Practice Address - Fax:248-677-3978
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680104643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health