Provider Demographics
NPI:1972890481
Name:JANSEN, MARY ANNA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNA
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:855-227-4230
Mailing Address - Fax:812-926-1668
Practice Address - Street 1:204 BRIDGEWAY ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001
Practice Address - Country:US
Practice Address - Phone:855-227-4230
Practice Address - Fax:812-926-1668
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201185890Medicaid
IN490250001Medicare PIN