Healthcare Provider Details

I. General information

NPI: 1952020257
Provider Name (Legal Business Name): JAN DAVID ANDRUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVE ANDRUS

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N IDAHO RD
NEWMAN LAKE WA
99025-9557
US

IV. Provider business mailing address

1121 E MULLAN AVE APT 2
COEUR D ALENE ID
83814-4054
US

V. Phone/Fax

Practice location:
  • Phone: 208-329-7676
  • Fax:
Mailing address:
  • Phone: 208-329-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: