Provider Demographics
NPI:1982846770
Name:JENSEN, JODY MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:MICHELLE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CARMEN LN
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7729
Mailing Address - Country:US
Mailing Address - Phone:805-928-7361
Mailing Address - Fax:805-928-5742
Practice Address - Street 1:135 CARMEN LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7729
Practice Address - Country:US
Practice Address - Phone:805-928-7361
Practice Address - Fax:805-928-5742
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19909OtherPHYSICIAN ASSISTANT COMMITTEE LICENSE NUMBER
CA12287854OtherCAQH PROVIDER NUMBER
CABX275XMedicare PIN
CA12287854OtherCAQH PROVIDER NUMBER
CA19909OtherPHYSICIAN ASSISTANT COMMITTEE LICENSE NUMBER