Provider Demographics
NPI:1457335044
Name:JANSEN, CYNTHIA S (PAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:S
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:10705 TOWN SQUARE DR NE STE 210
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8187
Practice Address - Country:US
Practice Address - Phone:763-284-2992
Practice Address - Fax:763-427-8131
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN764480900Medicaid