Healthcare Provider Details

I. General information

NPI: 1164054052
Provider Name (Legal Business Name): JEREMY DEAN JANSEN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 09/06/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 NE 3RD ST STE 111
BEND OR
97701-3888
US

IV. Provider business mailing address

4500 SERGEANT RD
SIOUX CITY IA
51106-4705
US

V. Phone/Fax

Practice location:
  • Phone: 800-748-3243
  • Fax:
Mailing address:
  • Phone: 712-274-2949
  • Fax: 712-274-8072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22223
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH0017215
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: