Provider Demographics
NPI:1083145577
Name:JENSEN, WILLIAM JOHN
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JOHN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 LONDON RD APT 204
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2235
Mailing Address - Country:US
Mailing Address - Phone:920-843-3312
Mailing Address - Fax:
Practice Address - Street 1:3820 LONDON RD APT 204
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2235
Practice Address - Country:US
Practice Address - Phone:920-843-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer