MEDICARE: SANDRA BETHEL JENSE APRN

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	363LA2100X	Acute Care Nurse Practitioner	6617074-4405	UT

General Provider Information

NPI Number	:	1104258763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA BETHEL JENSE APRN

Provider Business Mailing Address
First Line	:	522 E 100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1905
Country	:	US
Telephone Number	:	801-485-5055
Fax Number	:	801-467-3296

Provider Business Practice Location Address
First Line	:	522 E 100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1905
Country	:	US
Telephone Number	:	801-485-5055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	02/25/2020

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