Provider Demographics
NPI:1891153714
Name:JENSEN, TIM LEROY (MOTR/L)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:LEROY
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MOTR/L
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 5
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84326-0005
Mailing Address - Country:US
Mailing Address - Phone:435-232-4279
Mailing Address - Fax:888-668-5207
Practice Address - Street 1:2055 N 1450 E
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2086
Practice Address - Country:US
Practice Address - Phone:435-363-3732
Practice Address - Fax:888-668-5207
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9424731-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist