Provider Demographics
NPI:1114331485
Name:JENSEN, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6565
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN CLUB
Mailing Address - State:CA
Mailing Address - Zip Code:93222-6565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16501 OAKWOOD
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN CLUB
Practice Address - State:CA
Practice Address - Zip Code:93222
Practice Address - Country:US
Practice Address - Phone:661-473-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist