Provider Demographics
NPI:1831553049
Name:VAN MAANEN, JESSE R (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:VAN MAANEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4298
Mailing Address - Country:US
Mailing Address - Phone:641-672-3394
Mailing Address - Fax:641-672-3336
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4298
Practice Address - Country:US
Practice Address - Phone:641-672-3394
Practice Address - Fax:641-672-3336
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAMD-48817208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program