Provider Demographics
NPI:1205475993
Name:JANSEN, SUSANNE SHAW (PT, DPT)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:SHAW
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 VISAGE DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29626-4054
Mailing Address - Country:US
Mailing Address - Phone:864-934-1837
Mailing Address - Fax:
Practice Address - Street 1:2005 E GREENVILLE ST STE 119
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1575
Practice Address - Country:US
Practice Address - Phone:864-964-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist