Basic Information
| Provider Information | |||||||||
| NPI: | 1639623705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUKE | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | LIDDLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N FREEDOM BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846011677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013734760 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 N FREEDOM BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846011677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013734760 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2016 | ||||||||
| LastUpdateDate: | 08/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.