Provider Demographics
NPI:1093084303
Name:JENSEN PROFESSIONAL VENTURES PC
Entity Type:Organization
Organization Name:JENSEN PROFESSIONAL VENTURES PC
Other - Org Name:JENSEN'S COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:734-604-4586
Mailing Address - Street 1:968 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1586
Mailing Address - Country:US
Mailing Address - Phone:734-429-9053
Mailing Address - Fax:734-944-3934
Practice Address - Street 1:968 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1586
Practice Address - Country:US
Practice Address - Phone:734-429-9053
Practice Address - Fax:734-944-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010097213336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133161OtherPK
2376211OtherNCPDP PROVIDER IDENTIFICATION NUMBER