Provider Demographics
NPI:1245690114
Name:JENSEN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 ADIDAS RD
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-6106
Mailing Address - Country:US
Mailing Address - Phone:269-369-6719
Mailing Address - Fax:
Practice Address - Street 1:968 W MITCHELL HAMMOCK RD STE 1050
Practice Address - Street 2:4
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8119
Practice Address - Country:US
Practice Address - Phone:407-890-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253720363LF0000X
FLAPRN11029492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily