Provider Demographics
NPI:1740246263
Name:JANSEN, GERARD A (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:A
Last Name:JANSEN
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N RILEY ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1262
Mailing Address - Country:US
Mailing Address - Phone:260-347-1150
Mailing Address - Fax:260-347-1155
Practice Address - Street 1:402 N RILEY ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1262
Practice Address - Country:US
Practice Address - Phone:260-347-1150
Practice Address - Fax:260-347-1155
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN350011194OtherRAILROAD MEDICARE
IN000000184397OtherANTHEM/BCBS
IN100189090AMedicaid
IN000000184397OtherANTHEM/BCBS
IN218580BMedicare ID - Type Unspecified