Provider Demographics
NPI:1437108834
Name:JENSEN, BRUCE T
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:T
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
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 134
Mailing Address - Street 2:
Mailing Address - City:PORT GAMBLE
Mailing Address - State:WA
Mailing Address - Zip Code:98364-0134
Mailing Address - Country:US
Mailing Address - Phone:360-437-0331
Mailing Address - Fax:360-297-7772
Practice Address - Street 1:26129 CALVARY LN NE
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-7404
Practice Address - Country:US
Practice Address - Phone:360-437-0331
Practice Address - Fax:360-297-7772
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602049582332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225215288OtherNPI
WA9049206Medicaid
WA9049206Medicaid