Provider Demographics
NPI:1831569235
Name:VAN CHOFF, JAN MICHELE (LCSW)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:MICHELE
Last Name:VAN CHOFF
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 1:15520 DANIEL BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4744
Mailing Address - Country:US
Mailing Address - Phone:228-314-3626
Mailing Address - Fax:228-314-3141
Practice Address - Street 1:2059 E PASS RD STE 4
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3761
Practice Address - Country:US
Practice Address - Phone:228-314-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA130931041C0700X
FLSW 91561041C0700X
MSC82281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08856031Medicaid