Provider Demographics
NPI:1275542029
Name:JANSEN, MARK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:JANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5325
Mailing Address - Country:US
Mailing Address - Phone:870-246-2471
Mailing Address - Fax:870-246-2476
Practice Address - Street 1:3004 PINE ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5325
Practice Address - Country:US
Practice Address - Phone:870-246-2471
Practice Address - Fax:870-246-2476
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101476001Medicaid
AR101476001Medicaid
AR52639Medicare PIN