Provider Demographics
NPI:1649229857
Name:JANSMA, KELLY N (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:N
Last Name:JANSMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:N
Other - Last Name:VAN HAAFTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1620 N ANKENY BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4111
Mailing Address - Country:US
Mailing Address - Phone:515-963-7902
Mailing Address - Fax:844-493-4932
Practice Address - Street 1:1620 N ANKENY BLVD STE 106
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4111
Practice Address - Country:US
Practice Address - Phone:515-963-7902
Practice Address - Fax:844-493-4932
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02079Medicare UPIN
P00370252Medicare PIN
I13373Medicare PIN
I13371Medicare PIN
I13369Medicare PIN
I13367Medicare PIN
IA1449637Medicaid
I13371Medicare PIN
I13369Medicare PIN
I13367Medicare PIN