Provider Demographics
NPI:1932191863
Name:JANSEN, VICTORIA L (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:JANSEN
Suffix:
Gender:F
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:PO BOX 419059
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9059
Mailing Address - Country:US
Mailing Address - Phone:618-277-7500
Mailing Address - Fax:618-277-4623
Practice Address - Street 1:4 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2965
Practice Address - Country:US
Practice Address - Phone:618-277-7500
Practice Address - Fax:618-277-4236
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016019207R00000X, 208000000X
IL036.104122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156820005OtherMEDICARE PTAN
MO156820005OtherMEDICARE PTAN