Provider Demographics
NPI:1255621637
Name:JENSEN, PATRICIA (LPN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 E FAIRVIEW AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8048
Mailing Address - Country:US
Mailing Address - Phone:208-887-6283
Mailing Address - Fax:208-887-7759
Practice Address - Street 1:845 E FAIRVIEW AVE STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8048
Practice Address - Country:US
Practice Address - Phone:208-887-6283
Practice Address - Fax:208-887-7759
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-9105164W00000X
225700000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8059118Medicaid