Provider Demographics
NPI:1154855054
Name:JANSEN, JOHN MICHAEL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:JANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 TATES CREEK RD STE 302
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3400
Mailing Address - Country:US
Mailing Address - Phone:859-269-4604
Mailing Address - Fax:
Practice Address - Street 1:3320 TATES CREEK RD STE 302
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3400
Practice Address - Country:US
Practice Address - Phone:859-269-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics