Provider Demographics
NPI:1972537918
Name:JANSEN, EDWARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:JANSEN
Suffix:
Gender:M
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 MARVIN RD NE
Practice Address - Street 2:PMG SW WA HAWKS PRAIRIE IM
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3138
Practice Address - Country:US
Practice Address - Phone:360-923-4600
Practice Address - Fax:360-923-4663
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8304495Medicaid
WA5389380OtherAETNA
WA0201569OtherLABOR AND INDRUSTRIES
WA4764JAOtherREGENCE
WA0201569OtherLABOR AND INDRUSTRIES
WA4764JAOtherREGENCE