Provider Demographics
NPI:1962800060
Name:JANSEN, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 E BROADWAY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:IL
Practice Address - Zip Code:62293
Practice Address - Country:US
Practice Address - Phone:618-224-7366
Practice Address - Fax:618-224-9781
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily