MEDICARE: MRS. BROOKE A. 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	156F00000X	Technician/Technologist	1318673	NY

General Provider Information

NPI Number	:	1437410081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BROOKE A. JENSEN

Provider Business Mailing Address
First Line	:	99305 HICKORY DR
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3416
Country	:	US
Telephone Number	:	315-681-6960
Fax Number	:

Provider Business Practice Location Address
First Line	:	99305 HICKORY DR
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3416
Country	:	US
Telephone Number	:	315-681-6960
Fax Number	:

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

Provider Enumeration Date	:	05/30/2012
Last Update Date	:	05/30/2012

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