Provider Demographics
NPI:1568417970
Name:JANSEN, GARY (DC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JANSEN
Suffix:
Gender:M
Credentials:DC
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 550
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-0550
Mailing Address - Country:US
Mailing Address - Phone:503-625-2290
Mailing Address - Fax:503-625-6297
Practice Address - Street 1:22021 SW SHERWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9327
Practice Address - Country:US
Practice Address - Phone:503-625-2290
Practice Address - Fax:503-625-6297
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-1755111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112050OtherKAISER
OR291856Medicaid
OR291856Medicaid
OR112050OtherKAISER
OR137149Medicare PIN