Provider Demographics
NPI:1013908995
Name:JANSEN, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
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 1:3702 S STATE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5096
Mailing Address - Country:US
Mailing Address - Phone:801-288-2634
Mailing Address - Fax:801-288-1186
Practice Address - Street 1:3702 S STATE ST STE 107
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-5096
Practice Address - Country:US
Practice Address - Phone:801-288-2634
Practice Address - Fax:801-288-1186
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6555293-1205207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4828000340001Medicaid
MAA36299Medicare ID - Type Unspecified
MA2067790Medicaid