Provider Demographics
NPI:1104821883
Name:JANSEN, STACY L (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-845-0545
Mailing Address - Fax:417-845-0548
Practice Address - Street 1:510 PARK ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:MO
Practice Address - Zip Code:64831-9280
Practice Address - Country:US
Practice Address - Phone:417-845-0545
Practice Address - Fax:417-845-0548
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2000156458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00279800OtherRR MEDICARE
MO129295OtherANTHEM
P00279800OtherRR MEDICARE