Provider Demographics
NPI:1659794402
Name:JENSEN, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
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 1:5410 W 13680 S
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1710
Mailing Address - Country:US
Mailing Address - Phone:801-322-1001
Mailing Address - Fax:801-359-3864
Practice Address - Street 1:68 S 600 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-1007
Practice Address - Country:US
Practice Address - Phone:801-322-1001
Practice Address - Fax:801-359-3864
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker