Provider Demographics
NPI:1235210592
Name:JANSEN, LAURA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:A
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:314-454-2523
Practice Address - Street 1:1221 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-1002
Practice Address - Country:US
Practice Address - Phone:434-924-5129
Practice Address - Fax:434-924-9068
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180141022084N0402X
VA01012522792084N0400X
WAMD000432792084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200061331Medicaid
WA8389413Medicaid
8802492Medicare PIN
I03291Medicare UPIN