Provider Demographics
NPI:1417427444
Name:JANSEN, NICOLE MARIAH (MS OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIAH
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 KANSAS CITY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3673
Mailing Address - Country:US
Mailing Address - Phone:605-222-7336
Mailing Address - Fax:605-791-0631
Practice Address - Street 1:505 KANSAS CITY ST STE 3
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3673
Practice Address - Country:US
Practice Address - Phone:605-222-7336
Practice Address - Fax:605-791-0631
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1093225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist