Provider Demographics
NPI:1295180529
Name:JENSEN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
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 1:4128 WASHINGTON RD APT 107
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4215
Mailing Address - Country:US
Mailing Address - Phone:262-210-9456
Mailing Address - Fax:
Practice Address - Street 1:4128 WASHINGTON RD APT 107
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4215
Practice Address - Country:US
Practice Address - Phone:262-210-9456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI223348-30163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse