Healthcare Provider Details

I. General information

NPI: 1497187074
Provider Name (Legal Business Name): JACOB JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MAPLE ST S
TURTLE LAKE WI
54889
US

IV. Provider business mailing address

119 ANETA AVE
ALMENA WI
54805
US

V. Phone/Fax

Practice location:
  • Phone: 715-986-2225
  • Fax: 715-986-4079
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16700-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: