Provider Demographics
NPI:1053854091
Name:JENSEN, CONNIE (LMP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7104 265TH ST NW
Mailing Address - Street 2:SUITE 115
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-6250
Mailing Address - Country:US
Mailing Address - Phone:360-322-8549
Mailing Address - Fax:
Practice Address - Street 1:7104 265TH ST NW
Practice Address - Street 2:SUITE 115
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6250
Practice Address - Country:US
Practice Address - Phone:360-322-8549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60678986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist