MEDICARE: TARA 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	174400000X	Specialist
2	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1992195408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA JENSEN

Provider Business Mailing Address
First Line	:	7 PINE ST
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4260
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 PINE ST
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4260
Country	:	US
Telephone Number	:	631-875-3590
Fax Number	:

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

Provider Enumeration Date	:	02/04/2015
Last Update Date	:	02/04/2015

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