Provider Demographics
NPI:1043558463
Name:JENSEN, KRYSTIE DAWN (RPH)
Entity type:Individual
Prefix:
First Name:KRYSTIE
Middle Name:DAWN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 E RANCH CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3608
Mailing Address - Country:US
Mailing Address - Phone:417-830-2292
Mailing Address - Fax:
Practice Address - Street 1:1157 E RANCH CT
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3608
Practice Address - Country:US
Practice Address - Phone:417-830-2292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018504183500000X
MO042481183500000X
UT7787049-1701183500000X
UT7787049-8911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist