Healthcare Provider Details

I. General information

NPI: 1083145577
Provider Name (Legal Business Name): MR. WILLIAM JOHN JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2017
Last Update Date: 03/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 LONDON RD APT 204
DULUTH MN
55804-2235
US

IV. Provider business mailing address

3820 LONDON RD APT 204
DULUTH MN
55804-2235
US

V. Phone/Fax

Practice location:
  • Phone: 920-843-3312
  • Fax:
Mailing address:
  • Phone: 920-843-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: