Healthcare Provider Details

I. General information

NPI: 1437108834
Provider Name (Legal Business Name): BRUCE T JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26129 CALVARY LN NE SUITE 200
KINGSTON WA
98346-7404
US

IV. Provider business mailing address

PO BOX 134
PORT GAMBLE WA
98364-0134
US

V. Phone/Fax

Practice location:
  • Phone: 360-437-0331
  • Fax: 360-297-7772
Mailing address:
  • Phone: 360-437-0331
  • Fax: 360-297-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number602049582
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: