Provider Demographics
NPI:1194558940
Name:MATTIE-JENSEN, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:MATTIE-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 1:6428 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-5209
Mailing Address - Country:US
Mailing Address - Phone:414-431-8763
Mailing Address - Fax:
Practice Address - Street 1:4314 GARDEN DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-3940
Practice Address - Country:US
Practice Address - Phone:414-431-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10235124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist