Provider Demographics
NPI:1821557067
Name:JANSEN, DEEPA (MD)
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3661 PITZEN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-3734
Mailing Address - Country:US
Mailing Address - Phone:312-480-9167
Mailing Address - Fax:
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:203-863-3409
Practice Address - Fax:203-863-3446
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program