Provider Demographics
NPI:1760083133
Name:JENSEN, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
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:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:ANNABELLA
Mailing Address - State:UT
Mailing Address - Zip Code:84711-0323
Mailing Address - Country:US
Mailing Address - Phone:435-896-0378
Mailing Address - Fax:
Practice Address - Street 1:10 E 1300 S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-3122
Practice Address - Country:US
Practice Address - Phone:435-893-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4885827-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist