Healthcare Provider Details

I. General information

NPI: 1104874908
Provider Name (Legal Business Name): CONNIE E JENSEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S M ST SUITE 200
TACOMA WA
98405-3728
US

IV. Provider business mailing address

PO BOX 97115
LAKEWOOD WA
98497-0115
US

V. Phone/Fax

Practice location:
  • Phone: 253-475-5433
  • Fax: 253-473-6715
Mailing address:
  • Phone: 253-588-7911
  • Fax: 253-984-6774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30005224
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: