Provider Demographics
NPI:1124788153
Name:WHITE, JANEAN (ELECTROLOGIST)
Entity type:Individual
Prefix:MS
First Name:JANEAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:ELECTROLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4959 REBECCA DR
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1666
Mailing Address - Country:US
Mailing Address - Phone:208-251-7289
Mailing Address - Fax:
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3261
Practice Address - Country:US
Practice Address - Phone:208-251-7289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDEEI232029156F00000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDEEI232029OtherBUREAU OF OCCUPATIONAL LISCENSE
IDEEI232029OtherBUREAU OF OCCUPATIONAL LICENSES