Provider Demographics
NPI:1619015518
Name:JENSEN, TARA J (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:J
Other - Last Name:JEPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2380 N 400 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-713-9710
Mailing Address - Fax:435-753-8005
Practice Address - Street 1:1655 N 200 E
Practice Address - Street 2:SUITE 2
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1945
Practice Address - Country:US
Practice Address - Phone:435-753-1844
Practice Address - Fax:435-753-2986
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3617282401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD2434Medicaid