Provider Demographics
NPI:1639569916
Name:JENSEN, THERESA IRENE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:IRENE
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 1:8200 S SAGINAW ST STE 500
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2451
Mailing Address - Country:US
Mailing Address - Phone:810-953-8700
Mailing Address - Fax:810-953-8704
Practice Address - Street 1:8200 S SAGINAW ST STE 500
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2451
Practice Address - Country:US
Practice Address - Phone:810-953-8700
Practice Address - Fax:810-953-8704
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270666363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology