Provider Demographics
NPI:1194823385
Name:JENSEN, BRIAN CHARLES (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
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 1:1500 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3045
Mailing Address - Country:US
Mailing Address - Phone:920-794-1225
Mailing Address - Fax:920-794-7091
Practice Address - Street 1:2012 CRYSTAL SPRING RD
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-9368
Practice Address - Country:US
Practice Address - Phone:920-793-1765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist