Provider Demographics
NPI:1316283666
Name:DAVIS, JAN LYN (OC00000206)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:LYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OC00000206
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 200
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-0200
Mailing Address - Country:US
Mailing Address - Phone:360-885-6700
Mailing Address - Fax:360-885-6700
Practice Address - Street 1:11104 NE 149TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9565
Practice Address - Country:US
Practice Address - Phone:360-885-6700
Practice Address - Fax:360-885-6700
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00000206224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7989Medicaid