Provider Demographics
NPI:1952020257
Name:ANDRUS, JAN DAVID
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:DAVID
Last Name:ANDRUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVE
Other - Middle Name:
Other - Last Name:ANDRUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1121 E MULLAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4054
Mailing Address - Country:US
Mailing Address - Phone:208-329-7676
Mailing Address - Fax:
Practice Address - Street 1:6701 N IDAHO RD
Practice Address - Street 2:
Practice Address - City:NEWMAN LAKE
Practice Address - State:WA
Practice Address - Zip Code:99025-9557
Practice Address - Country:US
Practice Address - Phone:208-329-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral