Healthcare Provider Details

I. General information

NPI: 1669883385
Provider Name (Legal Business Name): CAROLE JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

849 S 600 W
OREM UT
84058-6788
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7850
  • Fax:
Mailing address:
  • Phone: 801-357-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number141951-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: