Provider Demographics
NPI:1215097548
Name:JANSEN, PAUL EDWARD (PHD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:JANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MOOSE HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-1730
Mailing Address - Country:US
Mailing Address - Phone:781-784-1796
Mailing Address - Fax:781-784-2927
Practice Address - Street 1:11 VANDERBILT AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5056
Practice Address - Country:US
Practice Address - Phone:781-769-5050
Practice Address - Fax:781-784-2927
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA864103TB0200X, 103TC0700X, 103TF0000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0503576Medicaid
MA0503576Medicaid