Provider Demographics
NPI:1881345031
Name:JANSEN, MALLORY (NP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:JANSEN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 W GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2819
Mailing Address - Country:US
Mailing Address - Phone:517-975-7206
Mailing Address - Fax:517-975-7210
Practice Address - Street 1:1140 E MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-9400
Practice Address - Fax:517-487-3148
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704272847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily