Healthcare Provider Details

I. General information

NPI: 1316665094
Provider Name (Legal Business Name): CARISSA JENSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S COUNTRY CLUB DR STE 3
MESA AZ
85210-5162
US

IV. Provider business mailing address

1300 S COUNTRY CLUB DR STE 3
MESA AZ
85210-5162
US

V. Phone/Fax

Practice location:
  • Phone: 480-827-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number279616
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN190141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: