Provider Demographics
NPI:1033436597
Name:JENSEN, SUSAN J (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 WILMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7132
Mailing Address - Country:US
Mailing Address - Phone:502-500-4512
Mailing Address - Fax:
Practice Address - Street 1:174 WILMINGTON DR
Practice Address - Street 2:
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7132
Practice Address - Country:US
Practice Address - Phone:502-500-4512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-3640225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist