=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326131335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY M JENSEN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 07/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6401 PRAIRIE ST SUITE 2300
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-7840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-727-7928
-----------------------------------------------------
Fax | 231-724-7844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1847
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49443-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-727-7948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5601003267
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601003267
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------