1225248370 NPI number — LAURIE ANNE JENSEN PH.D.

Table of content: LAURIE ANNE JENSEN PH.D. (NPI 1225248370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225248370 NPI number — LAURIE ANNE JENSEN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
LAURIE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1225248370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5905 LAKE EARL DR
Provider Second Line Business Mailing Address:
PO BOX 7000
Provider Business Mailing Address City Name:
CRESCENT CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95532-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-465-1000
Provider Business Mailing Address Fax Number:
707-465-9107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2596 N STOKESBERRY PL STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-9575
Provider Business Practice Location Address Fax Number:
208-898-8838
Provider Enumeration Date:
05/23/2007

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 , with the licence number:  PSY19054 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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