Basic Information
| Provider Information | |||||||||
| NPI: | 1497752844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANSEN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8040 CLEARVISTA PKWY | ||||||||
| Address2: | #240 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462565630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215450 | ||||||||
| FaxNumber: | 3176215453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01042313 | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000000085876 | 01 | IN | ANTHEM | OTHER | 000000764306 | 01 | IN | ANTHEM | OTHER | P01157045 | 01 | IN | MEDICARE RAILROAD | OTHER | 020024683 | 01 | IN | MEDICARE RAILROAD | OTHER | 100421600 | 05 | IN | MEDICAID | 100421600A | 05 | IN | MEDICAID |