Provider Demographics
NPI:1194014498
Name:JANSSEN, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:JANSSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-938-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:1739 FREEDOM DR STE 101
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3565
Practice Address - Country:US
Practice Address - Phone:888-938-3838
Practice Address - Fax:888-919-1083
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003980363A00000X, 363A00000X
MI5601006624363AS0400X, 364SN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No364SN0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003980OtherPHYSICIAN ASSISTANT LICENSE