Provider Demographics
NPI:1346797263
Name:JANSSEN, JOHN (PTA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JANSSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6563 W MAIN ST
Mailing Address - Street 2:SUITE: LOWER LEVEL
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4051
Mailing Address - Country:US
Mailing Address - Phone:269-488-3320
Mailing Address - Fax:269-372-6113
Practice Address - Street 1:6563 W MAIN ST
Practice Address - Street 2:SUITE: LOWER LEVEL
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-4051
Practice Address - Country:US
Practice Address - Phone:269-488-3320
Practice Address - Fax:269-372-6113
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant