Provider Demographics
NPI:1942622527
Name:JENSEN, MIKE (PRES)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PRES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 WASHINGTON BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-4152
Mailing Address - Country:US
Mailing Address - Phone:801-528-7350
Mailing Address - Fax:801-528-7355
Practice Address - Street 1:3480 WASHINGTON BLVD STE 107
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-4152
Practice Address - Country:US
Practice Address - Phone:801-528-7350
Practice Address - Fax:801-528-7355
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13746360OtherUTAH TAX CERTIFICATE