Provider Demographics
NPI:1104040047
Name:JENSON, LISA M (ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JENSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16317 WINTERGREEN ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-7734
Mailing Address - Country:US
Mailing Address - Phone:763-783-0849
Mailing Address - Fax:
Practice Address - Street 1:12555 UNIVERSITY AVE NW
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434
Practice Address - Country:US
Practice Address - Phone:763-506-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer