Basic Information
| Provider Information | |||||||||
| NPI: | 1447891247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LE ANNA | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 W BASS AVE | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730993945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056691801 | ||||||||
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| Practice Location | |||||||||
| Address1: | 670 W FIREWEED LN STE 160 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995032561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077700862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 151343 | AK | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 151343 | 05 | AK | MEDICAID |