Provider Demographics
NPI:1518967876
Name:JANSEN, CANDY MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:MICHELLE
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1779
Mailing Address - Country:US
Mailing Address - Phone:217-347-1243
Mailing Address - Fax:
Practice Address - Street 1:1301 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1779
Practice Address - Country:US
Practice Address - Phone:217-347-1243
Practice Address - Fax:217-347-1558
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15140Medicare ID - Type Unspecified