Provider Demographics
NPI:1053393215
Name:STJOHN, JANE (LPA, LCAS)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:STJOHN
Suffix:
Gender:F
Credentials:LPA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 TRADD CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6637
Mailing Address - Country:US
Mailing Address - Phone:910-343-6890
Mailing Address - Fax:910-332-1233
Practice Address - Street 1:1606 PHYSICIANS DR STE 104
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7348
Practice Address - Country:US
Practice Address - Phone:910-343-6890
Practice Address - Fax:910-332-1233
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC952103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107078Medicaid