=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356020481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE MARIE JANSEN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2023
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 BOARDWALK SPRINGS PL STE 111
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-4777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-299-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1054 WYNDGATE RIDGE DR
-----------------------------------------------------
City | LAKE SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-299-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2021014384
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------