MEDICARE: PHILLIP WAYNE JANSEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36207	SC
2	207Q00000X	Family Medicine Physician	066956	GA

General Provider Information

NPI Number	:	1407887318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP WAYNE JANSEN D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1705
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30903-1705
Country	:	US
Telephone Number	:	706-774-7263
Fax Number	:	706-774-7230

Provider Business Practice Location Address
First Line	:	1228 HIGHWAY 72 W
Second Line	:
City	:	GREENWOOD
State	:	SC
Zip	:	29649-1816
Country	:	US
Telephone Number	:	864-943-0549
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	03/15/2024

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