Provider Demographics
NPI:1972996296
Name:JENSEN, PAUL ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALAN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6971 9 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9633
Mailing Address - Country:US
Mailing Address - Phone:616-690-3318
Mailing Address - Fax:
Practice Address - Street 1:6455 US HIGHWAY 31 N
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MI
Practice Address - Zip Code:49690-9306
Practice Address - Country:US
Practice Address - Phone:231-938-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist