MEDICARE: MS. SUSAN E JENSEN PA-C

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	363AM0700X	Medical Physician Assistant	PA10003480	WA
2	363A00000X	Physician Assistant	PA10003480	WA

General Provider Information

NPI Number	:	1528150927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN E JENSEN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 421
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-0421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5781 MAIN ST
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-5426
Country	:	US
Telephone Number	:	541-654-0282
Fax Number	:

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	03/07/2024

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