Provider Demographics
NPI:1811060874
Name:JANSMA, MARY LUCILLE (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LUCILLE
Last Name:JANSMA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:600 N. BROADWAY
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2177
Mailing Address - Fax:360-414-2210
Practice Address - Street 1:600 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-0302
Practice Address - Country:US
Practice Address - Phone:360-414-2177
Practice Address - Fax:360-414-2210
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005737363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9652611Medicaid
WA8944406OtherCRIME VICTIMS
WA0220991OtherLABOR & IND.
WA8944406OtherCRIME VICTIMS
ORP57350Medicare UPIN