Healthcare Provider Details

I. General information

NPI: 1235957796
Provider Name (Legal Business Name): HEATHER LYN JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16573 AUBURN RD
GRASS VALLEY CA
95949-8762
US

IV. Provider business mailing address

16573 AUBURN RD
GRASS VALLEY CA
95949-8762
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-0631
  • Fax: 916-504-4328
Mailing address:
  • Phone: 530-273-0631
  • Fax: 916-504-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-QITUYB
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: