Healthcare Provider Details

I. General information

NPI: 1225240773
Provider Name (Legal Business Name): NICOLE RENEE JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 MERIDIAN AVE SUITE 150
SAN JOSE CA
95125-5350
US

IV. Provider business mailing address

2389 AZEVEDO PKWY
SAN JOSE CA
95125-6654
US

V. Phone/Fax

Practice location:
  • Phone: 408-979-2300
  • Fax:
Mailing address:
  • Phone: 408-999-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number30675
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: