Provider Demographics
NPI:1326131335
Name:JENSEN, KELLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-7948
Mailing Address - Fax:
Practice Address - Street 1:6401 PRAIRIE ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7840
Practice Address - Country:US
Practice Address - Phone:231-727-7928
Practice Address - Fax:231-724-7844
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003267363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34010012OtherMEDICARE PTAN