Provider Demographics
NPI:1760984892
Name:JENSEN, TODD (ATC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 ANNA ST NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4106
Mailing Address - Country:US
Mailing Address - Phone:719-351-5925
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 03669 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98430
Practice Address - Country:US
Practice Address - Phone:719-351-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1608442172255A2300X
ND704-152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty