Provider Demographics
NPI:1346303179
Name:JANSSEN, KATHLEEN L (OD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:JANSSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 BELINDER LN APT 2003
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5280
Mailing Address - Country:US
Mailing Address - Phone:773-501-0104
Mailing Address - Fax:847-367-0394
Practice Address - Street 1:2 HAWTHORN CTR
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1520
Practice Address - Country:US
Practice Address - Phone:847-367-0885
Practice Address - Fax:847-367-0394
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0507950256Medicare ID - Type Unspecified
IL154258Medicare UPIN