=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306083985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY JANSEN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2009
-----------------------------------------------------
Last Update Date | 02/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1750 N. RANDALL ROAD SUITE #120
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-608-6647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 N. RANDALL ROAD SUITE #120
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-608-6647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA053750
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------