MEDICARE: ALYSSA JENSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1053717223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALYSSA JENSEN

Provider Business Mailing Address
First Line	:	5901 W BEHREND DR
Second Line	:	APT #1122
City	:	GLENDALE
State	:	AZ
Zip	:	85308-6943
Country	:	US
Telephone Number	:	480-285-7359
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 W BEHREND DR
Second Line	:	APT #1122
City	:	GLENDALE
State	:	AZ
Zip	:	85308-6943
Country	:	US
Telephone Number	:	480-285-7359
Fax Number	:

Authorized Official
Title or Position	:	PA
Name	:	ALYSSA JENSEN
Credential	:
Telephone Number	:	480-285-7359

Provider Enumeration Date	:	11/14/2014
Last Update Date	:	11/14/2014

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