Provider Demographics
NPI:1104039031
Name:JANSSEN, JEREMY JACOB (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JACOB
Last Name:JANSSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 MICHELLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAVISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3091
Mailing Address - Country:US
Mailing Address - Phone:515-778-1945
Mailing Address - Fax:
Practice Address - Street 1:6825 MICHELLE AVE
Practice Address - Street 2:
Practice Address - City:LAVISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3091
Practice Address - Country:US
Practice Address - Phone:515-778-1945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2542225100000X
IA03741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist