Healthcare Provider Details

I. General information

NPI: 1104821883
Provider Name (Legal Business Name): STACY L JANSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 PARK ST
ANDERSON MO
64831-9280
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-845-0545
  • Fax: 417-845-0548
Mailing address:
  • Phone: 417-845-0545
  • Fax: 417-845-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2000156458
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: