Provider Demographics
NPI:1972901437
Name:JENSEN, BRADLEY (DPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 E WILMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2819
Mailing Address - Country:US
Mailing Address - Phone:801-581-2221
Mailing Address - Fax:801-581-2043
Practice Address - Street 1:1136 E WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2819
Practice Address - Country:US
Practice Address - Phone:801-581-2221
Practice Address - Fax:801-581-2043
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9045224-2401261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy