Basic Information
| Provider Information | |||||||||
| NPI: | 1255644233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | A.R.N.P | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ABBOTT | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | A.R.N.P. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT | ||||||||
| Address2: | SOUTH 2 ROOM 236 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152416228 | ||||||||
| FaxNumber: | 5152418685 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 WESTOWN PKWY | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502661301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152245225 | ||||||||
| FaxNumber: | 5152245235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 115062 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | J-115062 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1255644233 | 05 | IA | MEDICAID |