Healthcare Provider Details

I. General information

NPI: 1548445091
Provider Name (Legal Business Name): JAN T NODINE PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAN T NODINE

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 TAPPAN SPUR RD
WATKINSVILLE GA
30677-3845
US

IV. Provider business mailing address

1561 TAPPAN SPUR RD
WATKINSVILLE GA
30677-3845
US

V. Phone/Fax

Practice location:
  • Phone: 706-247-1436
  • Fax:
Mailing address:
  • Phone: 706-247-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number140654
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: