Provider Demographics
NPI:1881945558
Name:JENSON, MALLORY ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ROSE
Last Name:JENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ROSE
Other - Last Name:GESCHKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6141 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4303
Mailing Address - Country:US
Mailing Address - Phone:224-364-2273
Mailing Address - Fax:847-663-8290
Practice Address - Street 1:6141 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4303
Practice Address - Country:US
Practice Address - Phone:224-364-2273
Practice Address - Fax:847-663-8290
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004404363A00000X
IL085.004404363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.004404OtherILLINOIS STATE LICENSE NUMBER
IL385003174OtherILLINOIS CONTROLLED SUBSTANCE LICENSE