Provider Demographics
NPI:1063767085
Name:JANU, JEAN MARIE (MA, LPCC)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:JANU
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:TIERRA AMARILLA
Mailing Address - State:NM
Mailing Address - Zip Code:87575-0250
Mailing Address - Country:US
Mailing Address - Phone:575-588-7252
Mailing Address - Fax:575-588-9132
Practice Address - Street 1:US HWY 84 COUNTY RD. 324 #14
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575
Practice Address - Country:US
Practice Address - Phone:575-588-9506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM179641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1336177575OtherLISW