Provider Demographics
NPI:1356117592
Name:JENSEN, MARY JACQUELINE (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JACQUELINE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 KEARSAGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-9052
Mailing Address - Country:US
Mailing Address - Phone:928-706-5051
Mailing Address - Fax:
Practice Address - Street 1:80 ACOMA BLVD S STE 106
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6926
Practice Address - Country:US
Practice Address - Phone:928-706-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-26330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist