Provider Demographics
NPI:1942645577
Name:JANSEN, KELSEY R (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:R
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:R
Other - Last Name:VONDERHEIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9145
Mailing Address - Country:US
Mailing Address - Phone:812-634-1211
Mailing Address - Fax:812-634-9762
Practice Address - Street 1:1900 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9145
Practice Address - Country:US
Practice Address - Phone:812-634-1211
Practice Address - Fax:812-634-9762
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003807363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090771Medicaid
OHH253360Medicare PIN