Provider Demographics
NPI:1497187074
Name:JENSEN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
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 1:119 ANETA AVE
Mailing Address - Street 2:
Mailing Address - City:ALMENA
Mailing Address - State:WI
Mailing Address - Zip Code:54805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 MAPLE ST S
Practice Address - Street 2:
Practice Address - City:TURTLE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54889
Practice Address - Country:US
Practice Address - Phone:715-986-2225
Practice Address - Fax:715-986-4079
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16700-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist