Provider Demographics
NPI:1538211701
Name:SANFORD, JAN M (LPC-MH, QMHP, LSWA)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:M
Last Name:SANFORD
Suffix:
Gender:F
Credentials:LPC-MH, QMHP, LSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-3621
Mailing Address - Country:US
Mailing Address - Phone:605-886-6321
Mailing Address - Fax:605-886-6306
Practice Address - Street 1:309 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3621
Practice Address - Country:US
Practice Address - Phone:605-886-6321
Practice Address - Fax:605-886-6306
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH 2087101YM0800X, 101YP2500X
SDLSWA 2146104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN154887500Medicaid
SD20202OtherSIOUX VALLEY HEALTH PLAN
SD4997066OtherBLUE CROSS BLUE SHEILD
SD9173854OtherDAKOTACARE
11350OtherMIDLANDS CHOICE
SD46045OtherAVERA HEALTH PLAN
SD6575620Medicaid