Provider Demographics
NPI:1578131694
Name:JANSEN, GARRET JOHN (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:GARRET
Middle Name:JOHN
Last Name:JANSEN
Suffix:
Gender:M
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1255
Mailing Address - Country:US
Mailing Address - Phone:641-628-6623
Mailing Address - Fax:641-621-2223
Practice Address - Street 1:500 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1255
Practice Address - Country:US
Practice Address - Phone:641-628-6623
Practice Address - Fax:641-621-2223
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA109225235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA109225OtherLICENSE