=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063767325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMBER JENSEN M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2012
-----------------------------------------------------
Last Update Date | 07/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 MCCONNELL AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-7026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-482-5607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3322 MENTONE AVE APT #3
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-4667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-589-7802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------