Provider Demographics
NPI:1821370461
Name:JENSEN, ALAN JOEL (PA)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:JOEL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 POTOMAC WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4970
Mailing Address - Country:US
Mailing Address - Phone:208-528-8170
Mailing Address - Fax:208-552-5461
Practice Address - Street 1:3360 WASHINGTON PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8332
Practice Address - Country:US
Practice Address - Phone:208-528-8170
Practice Address - Fax:208-552-5461
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical