Healthcare Provider Details

I. General information

NPI: 1790727733
Provider Name (Legal Business Name): LISA ANN JENSEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SLC VA HEALTH CARE SYSTEM 500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

52 SCENIC HILLS CIR
NORTH SALT LAKE UT
84054-1539
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number352098-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: