1174659585 NPI number — JAN DOUGLASS

Table of content: (NPI 1174659585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174659585 NPI number — JAN DOUGLASS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAN DOUGLASS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174659585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78626-6643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 W UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78626-6643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-863-2297
Provider Business Practice Location Address Fax Number:
512-863-2975
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FERMAN
Authorized Official First Name:
DENA
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY PLAN COORDINATOR
Authorized Official Telephone Number:
314-993-6000

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  20963 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 142947 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4572283 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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