Provider Demographics
NPI:1093456345
Name:JENSEN, GLORIA STAR (MANUAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:STAR
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MANUAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-6758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-6758
Practice Address - Country:US
Practice Address - Phone:505-402-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty