Active NPI
Jan Garver Bacon, PHD
- Clinical Psychologist
- Lakewood, WA
National Provider Identifier
1457335820
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PY00001639
- Practice address
- 9125 Bridgeport Way SW Ste 102
Lakewood, WA 98499-2448 - Phone
- (253) 254-8284
- Fax
- (253) 276-0082
- NPI assigned
- Nov 30, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PY00001639 | WA | Primary |
Addresses
Primary practice location
9125 Bridgeport Way SW Ste 102
Lakewood, WA 98499-2448
Mailing address
9125 Bridgeport Way SW Ste 102
Lakewood, WA 98499-2448
Phone (253) 254-8284
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
- Opted out of Medicare
- Yes, effective Jun 1, 2018 through Jun 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PY00001639 | WA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1133308800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1524009600000",
"number": "1457335820",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9125 BRIDGEPORT WAY SW STE 102",
"city": "LAKEWOOD",
"state": "WA",
"postal_code": "984992448",
"telephone_number": "253-254-8284",
"fax_number": "253-276-0082"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9125 BRIDGEPORT WAY SW STE 102",
"city": "LAKEWOOD",
"state": "WA",
"postal_code": "984992448",
"telephone_number": "253-254-8284",
"fax_number": "253-276-0082"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BACON",
"first_name": "JAN",
"middle_name": "GARVER",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-11-30",
"last_updated": "2018-04-18",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "WA",
"license": "PY00001639",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lakewood, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 18, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.