Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | 20040740A | IN |
N | 103TC0700X | Clinical Psychologist | 20040740A | IN |
N | 103G00000X | Clinical Psychologist | IN20040740 | IN |
N | 103TC0700X | Clinical Psychologist | IN20040740 | IN |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 20040740A | IN |
Y | 103G00000X | Clinical Psychologist | 20040740A | IN |
Y | 103TC0700X | Clinical Psychologist | 20040740A | IN |
NPI | 1043214679 |
---|---|
Provider Name | Dr. Jan Earl Warner |
First Address | Mishawaka, IN 46545-3463 |
Second Address | Mishawaka, IN 46545-3463 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2005 |
Last Update Date | 03/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000196536 | BLUE CROSS BLUE SHIELD (01) | IN |
100383350A | (05) | IN |
235650A | (02) | IN |