Provider Demographics
NPI:1114319381
Name:JENSEN, MATTHEW ALLEN (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12187 KILBRIDE DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1277
Mailing Address - Country:US
Mailing Address - Phone:513-295-4678
Mailing Address - Fax:513-829-7458
Practice Address - Street 1:560 WESSEL DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3776
Practice Address - Country:US
Practice Address - Phone:513-829-2005
Practice Address - Fax:513-829-7458
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist