Basic Information
| Provider Information | |||||||||
| NPI: | 1508818550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PHY D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LINDSBORG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674561903 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1905 19TH ST | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675302502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207925700 | ||||||||
| FaxNumber: | 6207925742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1007 | KS | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 119803 | 01 | KS | BLU SHIELD | OTHER | 460800 | 01 | KS | FIRST GUARD | OTHER |