1053441139 NPI number — DR. NANCY L. JENSEN PHD

Table of content: DR. NANCY L. JENSEN PHD (NPI 1053441139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053441139 NPI number — DR. NANCY L. JENSEN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
NANCY
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053441139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 PLYMOUTH LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-6063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-612-0598
Provider Business Mailing Address Fax Number:
847-559-0651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 416
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-612-0598
Provider Business Practice Location Address Fax Number:
847-559-0651
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001636034 . This is a "BCBSIL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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