Provider Demographics
NPI:1386130201
Name:BUSSELL, JAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:BUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 SPUR 156
Mailing Address - Street 2:
Mailing Address - City:WASKOM
Mailing Address - State:TX
Mailing Address - Zip Code:75692-9129
Mailing Address - Country:US
Mailing Address - Phone:903-687-2586
Mailing Address - Fax:
Practice Address - Street 1:1204 HARPER DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-5712
Practice Address - Country:US
Practice Address - Phone:512-497-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13341101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)