Provider Demographics
NPI:1235210519
Name:TODD, JANSEN S (DO)
Entity Type:Individual
Prefix:
First Name:JANSEN
Middle Name:S
Last Name:TODD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 E DENMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-6110
Mailing Address - Country:US
Mailing Address - Phone:936-693-1224
Mailing Address - Fax:693-632-9322
Practice Address - Street 1:1702 E DENMAN AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-6110
Practice Address - Country:US
Practice Address - Phone:936-693-1224
Practice Address - Fax:693-632-9322
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114317402Medicaid
TX87X171OtherBC BS PIN
TX00R92ZMedicare PIN
TX114317402Medicaid