Healthcare Provider Details

I. General information

NPI: 1922031210
Provider Name (Legal Business Name): TRACY JANSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24A MAGOTHY BEACH RD
PASADENA MD
21122-4428
US

IV. Provider business mailing address

1111 BENFIELD BLVD SUITE 200
MILLERSVILLE MD
21108-3002
US

V. Phone/Fax

Practice location:
  • Phone: 410-255-2700
  • Fax: 410-437-1962
Mailing address:
  • Phone: 410-729-5100
  • Fax: 410-729-5156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0062357
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: