Provider Demographics
NPI:1467120865
Name:JANSEN, MATTHEW RYAN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:JANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 ARABIAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8090
Mailing Address - Country:US
Mailing Address - Phone:406-570-9080
Mailing Address - Fax:
Practice Address - Street 1:2430 ARABIAN AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-8090
Practice Address - Country:US
Practice Address - Phone:406-570-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCP007906A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant