Provider Demographics
NPI:1053563361
Name:PHELAN, JANE (APRN)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2578 66TH TER S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-5608
Mailing Address - Country:US
Mailing Address - Phone:803-616-3112
Mailing Address - Fax:
Practice Address - Street 1:2578 66TH TER S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-5608
Practice Address - Country:US
Practice Address - Phone:803-616-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03793364SP0809X
SC4266364SP0809X
NYF401380364SP0809X
FL9486153363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult