MEDICARE: STEPHANIE L JENSEN LRD

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	133V00000X	Registered Dietitian	1256	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45-0311334	OTHER	ND	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1346856002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE L JENSEN LRD

Provider Business Mailing Address
First Line	:	401 N 9TH ST
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58501-4506
Country	:	US
Telephone Number	:	701-712-4940
Fax Number	:	701-712-4159

Provider Business Practice Location Address
First Line	:	401 N 9TH ST
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58501-4506
Country	:	US
Telephone Number	:	701-712-4500
Fax Number	:

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

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	06/14/2023

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