Healthcare Provider Details

I. General information

NPI: 1871894584
Provider Name (Legal Business Name): KRISTINE JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N LAKE ST
MANISTIQUE MI
49854-1234
US

IV. Provider business mailing address

125 N LAKE ST
MANISTIQUE MI
49854-1234
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-2144
  • Fax: 906-341-5793
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number4704171469
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: