Provider Demographics
NPI:1093906513
Name:JANSEN, LYNDA RAE (OTR)
Entity Type:Individual
Prefix:MS
First Name:LYNDA
Middle Name:RAE
Last Name:JANSEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 NORTHPOINTE DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8238
Mailing Address - Country:US
Mailing Address - Phone:616-532-2250
Mailing Address - Fax:
Practice Address - Street 1:308 S MAIN
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8925
Practice Address - Country:US
Practice Address - Phone:616-696-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI52010000372225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236598Medicare PIN