Provider Demographics
NPI:1467749044
Name:JENSEN, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
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 1:590 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6154
Mailing Address - Country:US
Mailing Address - Phone:208-523-1090
Mailing Address - Fax:
Practice Address - Street 1:590 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6154
Practice Address - Country:US
Practice Address - Phone:208-523-1090
Practice Address - Fax:208-528-8681
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist