Provider Demographics
NPI:1154501062
Name:JANSEN, MICHAEL ALAN (PHD, LP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:JANSEN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 WASHINGTON AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7141
Mailing Address - Country:US
Mailing Address - Phone:616-355-3926
Mailing Address - Fax:616-393-6651
Practice Address - Street 1:854 WASHINGTON AVE STE 330
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7141
Practice Address - Country:US
Practice Address - Phone:616-355-3926
Practice Address - Fax:616-393-6651
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013771103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist