Provider Demographics
NPI:1629191523
Name:JANSEN, TED NICHOLAS (MA)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:NICHOLAS
Last Name:JANSEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 S HILLSDALE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9367
Mailing Address - Country:US
Mailing Address - Phone:517-425-4479
Mailing Address - Fax:
Practice Address - Street 1:1360 S HILLSDALE RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9367
Practice Address - Country:US
Practice Address - Phone:517-425-4479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health