Provider Demographics
NPI:1548577307
Name:JENSEN, ELAINA S (PMHNP, FNP)
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:S
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:ELAINA
Other - Middle Name:
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP, FNP
Mailing Address - Street 1:880 S EDISON ST UNIT 880A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4262
Mailing Address - Country:US
Mailing Address - Phone:512-705-1971
Mailing Address - Fax:844-638-4335
Practice Address - Street 1:2385 TABLE ROCK RD # 103
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1510
Practice Address - Country:US
Practice Address - Phone:512-705-1971
Practice Address - Fax:844-638-4335
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8376363L00000X
OR201701967NP-PP363LF0000X
NVAPRN00363363LF0000X, 363LP0808X
WAAP60853245363LP0808X
TXAP119327363LP0808X
OR201701966NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB127809OtherMEDICARE PROVIDER NUMBER