Provider Demographics
NPI:1407887318
Name:JANSEN, PHILLIP WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WAYNE
Last Name:JANSEN
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:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1228 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-1816
Practice Address - Country:US
Practice Address - Phone:864-943-0549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36207207Q00000X
GA066956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116016AMedicaid
GA003116016BMedicaid
SCSC2647F694Medicare PIN