Healthcare Provider Details

I. General information

NPI: 1346856002
Provider Name (Legal Business Name): STEPHANIE L JENSEN LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4506
US

IV. Provider business mailing address

401 N 9TH ST
BISMARCK ND
58501-4506
US

V. Phone/Fax

Practice location:
  • Phone: 701-712-4500
  • Fax:
Mailing address:
  • Phone: 701-712-4940
  • Fax: 701-712-4159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1256
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: