Provider Demographics
NPI:1447531199
Name:JENSEN, AMANDA ANNE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 N 400 E
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-7217
Mailing Address - Country:US
Mailing Address - Phone:801-689-1525
Mailing Address - Fax:801-689-1531
Practice Address - Street 1:2555 N 400 E
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7217
Practice Address - Country:US
Practice Address - Phone:801-689-1525
Practice Address - Fax:801-689-1531
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2774278-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist