Provider Demographics
NPI:1770181091
Name:JENSEN, TRACEY RANAE (LMT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:RANAE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 TURTLE CREST DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-1002
Mailing Address - Country:US
Mailing Address - Phone:949-573-2942
Mailing Address - Fax:
Practice Address - Street 1:261 TURTLE CREST DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92603-1002
Practice Address - Country:US
Practice Address - Phone:949-573-2942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76972225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist