Provider Demographics
NPI:1841607637
Name:JANSEN, KEVEN
Entity type:Individual
Prefix:
First Name:KEVEN
Middle Name:
Last Name:JANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 LIBERTY RD NE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-8926
Mailing Address - Country:US
Mailing Address - Phone:320-763-7831
Mailing Address - Fax:
Practice Address - Street 1:414 LIBERTY RD NE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-8926
Practice Address - Country:US
Practice Address - Phone:320-763-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist