Provider Demographics
NPI:1477652469
Name:JENSEN, JILL N (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:N
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:1001 RISEN SON BLVD
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-1910
Practice Address - Country:US
Practice Address - Phone:712-256-8600
Practice Address - Fax:712-256-8599
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001628363A00000X
NE1813363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0260125Medicaid
IA47068731712Medicaid
IA1477652469Medicaid
IAQ37627Medicare UPIN
IA1477652469Medicaid