Basic Information
| Provider Information | |||||||||
| NPI: | 1508930314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JANICE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | BOYNTON HEALTH SERVICE-UNIVERSITY OF MINNESOTA | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126241444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | BOYNTON HEALTH SERVICE-UNIVERSITY OF MINNESOTA | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126241444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 14389 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.