Provider Demographics
NPI:1922074293
Name:JANSEN, BRIAN WILLIAM (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:JANSEN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4556
Mailing Address - Country:US
Mailing Address - Phone:386-341-3666
Mailing Address - Fax:
Practice Address - Street 1:640 DR MARY MCLEOD BETHUNE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3012
Practice Address - Country:US
Practice Address - Phone:386-481-2261
Practice Address - Fax:386-481-2265
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist