Provider Demographics
NPI:1396599932
Name:JENSEN, CARLY JANE (NP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JANE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JANE
Other - Last Name:BURGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:147 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD STE 4601
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-4370
Practice Address - Fax:317-968-1254
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28210211A163WG0000X
IN71015489A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300095114Medicaid
IN1104324845OtherANTHEM PTAN
IN254330016OtherMEDICARE PTAN