Healthcare Provider Details

I. General information

NPI: 1134538002
Provider Name (Legal Business Name): LAURA JENSEN L.M.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 CARY ALGONQUIN RD STE C
CARY IL
60013-2084
US

IV. Provider business mailing address

395 CARY ALGONQUIN RD STE C
CARY IL
60013-2084
US

V. Phone/Fax

Practice location:
  • Phone: 847-639-0010
  • Fax:
Mailing address:
  • Phone: 847-639-0010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.002476
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: