Healthcare Provider Details

I. General information

NPI: 1912087867
Provider Name (Legal Business Name): LISA K JENSEN FNP CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 UPPER PLAIN
BRADFORD VT
05033
US

IV. Provider business mailing address

88 ASH HILL ROAD
LYMAN NH
03585
US

V. Phone/Fax

Practice location:
  • Phone: 802-222-4722
  • Fax: 802-222-4709
Mailing address:
  • Phone: 603-838-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0256212301
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1010025554
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: