Provider Demographics
NPI:1629469366
Name:JENSEN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:FRANCIS
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1500 PINECREST AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-4326
Mailing Address - Country:US
Mailing Address - Phone:715-345-7175
Mailing Address - Fax:715-345-1745
Practice Address - Street 1:1500 PINECREST AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-4326
Practice Address - Country:US
Practice Address - Phone:715-345-7175
Practice Address - Fax:715-345-1745
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11944-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist