Provider Demographics
NPI:1780389957
Name:HART, JANELL STEPHANIE
Entity type:Individual
Prefix:
First Name:JANELL
Middle Name:STEPHANIE
Last Name:HART
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 1:3015 CLAY AVE # 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-1410
Mailing Address - Country:US
Mailing Address - Phone:619-804-7320
Mailing Address - Fax:
Practice Address - Street 1:5333 MISSION CENTER RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1347
Practice Address - Country:US
Practice Address - Phone:619-997-4510
Practice Address - Fax:619-984-5440
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-KOGNFD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker