Provider Demographics
NPI:1447891247
Name:JANSEN, AMY LE ANNA (LPN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LE ANNA
Last Name:JANSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W BASS AVE
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-3945
Mailing Address - Country:US
Mailing Address - Phone:405-669-1801
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK151343164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK151343Medicaid