Provider Demographics
NPI:1497030118
Name:JENSEN, EMILY ELISE (PA)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:ELISE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17735 S WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-8636
Mailing Address - Country:US
Mailing Address - Phone:630-643-3886
Mailing Address - Fax:
Practice Address - Street 1:391 S BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3411
Practice Address - Country:US
Practice Address - Phone:630-226-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004165363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004165OtherSTATE MEDICAL LICENSE