Provider Demographics
NPI:1114993441
Name:JENSEN, STACY K (APRN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:JENSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E BROADWAY
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3700
Mailing Address - Country:US
Mailing Address - Phone:502-629-2500
Mailing Address - Fax:502-629-2055
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-272-5339
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4444P363L00000X
LA3004444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000600371OtherANTHEM
KY00546214Medicare Oscar/Certification
KYQ30481Medicare UPIN