Healthcare Provider Details

I. General information

NPI: 1942000468
Provider Name (Legal Business Name): ROGER JANSEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 EAST PARIS AVE SE
GRAND RAPIDS MI
49546-6190
US

IV. Provider business mailing address

2155 EAST PARIS AVE SE STE 220
GRAND RAPIDS MI
49546-6195
US

V. Phone/Fax

Practice location:
  • Phone: 616-581-2755
  • Fax:
Mailing address:
  • Phone: 616-581-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number6362100084
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: