Provider Demographics
NPI:1952527392
Name:JANSEN CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:JANSEN CHIROPRACTIC CLINIC PC
Other - Org Name:MT ANGEL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-625-2290
Mailing Address - Street 1:22021 SW SHERWOOD BLVD
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9327
Mailing Address - Country:US
Mailing Address - Phone:503-625-2290
Mailing Address - Fax:503-625-6297
Practice Address - Street 1:22021 SW SHERWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9327
Practice Address - Country:US
Practice Address - Phone:503-625-2290
Practice Address - Fax:503-625-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-1755111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291856Medicaid
ORT67752Medicare UPIN
OR137148Medicare PIN