Provider Demographics
NPI:1619272119
Name:CONNIE E. JENSEN PLLC
Entity Type:Organization
Organization Name:CONNIE E. JENSEN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:253-588-7911
Mailing Address - Street 1:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-984-6774
Practice Address - Street 1:502 S M ST STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3728
Practice Address - Country:US
Practice Address - Phone:253-588-7911
Practice Address - Fax:253-984-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005224367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30005224OtherMEDICAL LICENSE