Provider Demographics
NPI:1770138950
Name:HOUSTON, JENSEN
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13612 CREWE ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4235
Mailing Address - Country:US
Mailing Address - Phone:818-212-0918
Mailing Address - Fax:
Practice Address - Street 1:505 N TUSTIN AVE STE 190
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3777
Practice Address - Country:US
Practice Address - Phone:714-784-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant