Provider Demographics
NPI:1114200599
Name:JENSEN, CLINT L (PHARMD)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:L
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 CHUBBUCK AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-237-3900
Mailing Address - Fax:208-237-4955
Practice Address - Street 1:4845 CHUBBUCK AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-237-3900
Practice Address - Fax:208-237-4955
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist