Provider Demographics
NPI:1902091093
Name:LOEB, JAN (LMSW (PROVISIONAL))
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:LOEB
Suffix:
Gender:F
Credentials:LMSW (PROVISIONAL)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 MONTGOMERY BLVD NE STE F
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1529
Mailing Address - Country:US
Mailing Address - Phone:505-880-0100
Mailing Address - Fax:505-880-0102
Practice Address - Street 1:540 CHAMA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3594
Practice Address - Country:US
Practice Address - Phone:505-265-0753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-059351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical