Provider Demographics
NPI:1164707477
Name:JENSEN, MIKELL JO
Entity Type:Individual
Prefix:
First Name:MIKELL
Middle Name:JO
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 1:474 W 200 N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4505
Mailing Address - Country:US
Mailing Address - Phone:435-628-0612
Mailing Address - Fax:
Practice Address - Street 1:960 N DIXIE DOWNS RD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4206
Practice Address - Country:US
Practice Address - Phone:435-628-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other