Provider Demographics
NPI:1336569623
Name:WEITH, JAN CATHERINE
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:CATHERINE
Last Name:WEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JAN
Other - Middle Name:CATHERINE
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14415 ASPEN LN
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-8861
Mailing Address - Country:US
Mailing Address - Phone:573-517-1543
Mailing Address - Fax:
Practice Address - Street 1:117 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1337
Practice Address - Country:US
Practice Address - Phone:573-517-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014841101Y00000X, 101YM0800X, 101YS0200X
MO2012104841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool