Provider Demographics
NPI:1174198311
Name:JENSEN, ELIZABETH A
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:SNOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:185 N VERNAL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2100
Mailing Address - Country:US
Mailing Address - Phone:435-790-1306
Mailing Address - Fax:307-782-3122
Practice Address - Street 1:185 N VERNAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2100
Practice Address - Country:US
Practice Address - Phone:435-790-1306
Practice Address - Fax:307-782-3122
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT170508265OtherDRIVERS LICENSE