Provider Demographics
NPI:1932862091
Name:JENSEN, JACKLYN GRACE (RD)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:GRACE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14604 NE 42ND PL APT N405
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3135
Mailing Address - Country:US
Mailing Address - Phone:435-731-4079
Mailing Address - Fax:
Practice Address - Street 1:14604 NE 42ND PL APT N405
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3135
Practice Address - Country:US
Practice Address - Phone:435-731-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1292133V00000X
WADI61202063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered