Healthcare Provider Details

I. General information

NPI: 1679289367
Provider Name (Legal Business Name): ALYSSE JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone: 813-745-7365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120369
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: