Provider Demographics
NPI:1871964585
Name:KRUSE, JAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:KRUSE
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 1:11060 HILDRETH CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-9272
Mailing Address - Country:US
Mailing Address - Phone:805-340-1378
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-9272
Practice Address - Country:US
Practice Address - Phone:805-340-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)