Basic Information
| Provider Information | |||||||||
| NPI: | 1730859414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2412 BEAR HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729167442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798830618 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6801 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792744100 | ||||||||
| FaxNumber: | 4792744199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2021 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 213228 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.