Provider Demographics
NPI:1548445091
Name:NODINE, JAN T (PMHCNS-BC)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:T
Last Name:NODINE
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:T
Other - Last Name:NODINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1561 TAPPAN SPUR RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-3845
Mailing Address - Country:US
Mailing Address - Phone:706-247-1436
Mailing Address - Fax:
Practice Address - Street 1:1561 TAPPAN SPUR RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-3845
Practice Address - Country:US
Practice Address - Phone:706-247-1436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA140654364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult