1295118941 NPI number — DR. TERA JEAN JANSEN M.A., PSY.D.

Table of content: MRS. CHARLENE Y SONG M.D (NPI 1366537474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295118941 NPI number — DR. TERA JEAN JANSEN M.A., PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANSEN
Provider First Name:
TERA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.A., PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295118941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
928 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 300, OFFICE #10
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-403-4268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
928 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 300, OFFICE #10
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-403-4268
Provider Business Practice Location Address Fax Number:
612-999-1792
Provider Enumeration Date:
06/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP6091 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 025499-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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