Basic Information
| Provider Information | |||||||||
| NPI: | 1972537918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2555 MARVIN RD NE | ||||||||
| Address2: | PMG SW WA HAWKS PRAIRIE IM | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985163138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609234600 | ||||||||
| FaxNumber: | 3609234663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00025461 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8304495 | 05 | WA | MEDICAID | 5389380 | 01 | WA | AETNA | OTHER | 0201569 | 01 | WA | LABOR AND INDRUSTRIES | OTHER | 4764JA | 01 | WA | REGENCE | OTHER |