Provider Demographics
NPI:1205269669
Name:JANSEN, KRISTINE MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:MARIE
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:GRANACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:363 JUNGERMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:ST. PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:636-928-3877
Mailing Address - Fax:
Practice Address - Street 1:363 JUNGERMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-5371
Practice Address - Country:US
Practice Address - Phone:636-928-3877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01957225100000X
IL070.018960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist