Healthcare Provider Details

I. General information

NPI: 1437667086
Provider Name (Legal Business Name): JACOB JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HIGH ST
EUGENE OR
97401-3297
US

IV. Provider business mailing address

2087 ALDER ST
EUGENE OR
97405-2939
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-7427
  • Fax: 541-505-9306
Mailing address:
  • Phone: 415-419-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23939
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: