Healthcare Provider Details

I. General information

NPI: 1114200599
Provider Name (Legal Business Name): CLINT L JENSEN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 CHUBBUCK AVE
CHUBBUCK ID
83202
US

IV. Provider business mailing address

4845 CHUBBUCK AVE
CHUBBUCK ID
83202
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-3900
  • Fax: 208-237-4955
Mailing address:
  • Phone: 208-237-3900
  • Fax: 208-237-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4731
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: