Provider Demographics
NPI:1275363517
Name:JENSEN, KRISTAL M (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KRISTAL
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 N 95TH AVE APT 333
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-1338
Mailing Address - Country:US
Mailing Address - Phone:541-910-1157
Mailing Address - Fax:
Practice Address - Street 1:1 W FIRESTORM WAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3216
Practice Address - Country:US
Practice Address - Phone:541-910-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-1001022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer