1578729901 NPI number — CANDICE JENSEN MD PLLC

Table of content: (NPI 1578729901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578729901 NPI number — CANDICE JENSEN MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANDICE JENSEN MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1578729901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2503 S AVE A
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-7173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-344-3250
Provider Business Mailing Address Fax Number:
928-344-3253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2503 S AVE A
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-7173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-344-3250
Provider Business Practice Location Address Fax Number:
928-344-3253
Provider Enumeration Date:
08/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
928-344-3250

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  38206 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z148161 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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