Provider Demographics
NPI:1306447610
Name:JENSEN, LEANN MARY
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:MARY
Last Name: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 1:16775 76TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MOORETON
Mailing Address - State:ND
Mailing Address - Zip Code:58061-9740
Mailing Address - Country:US
Mailing Address - Phone:701-640-6167
Mailing Address - Fax:
Practice Address - Street 1:16775 76TH ST SE
Practice Address - Street 2:
Practice Address - City:MOORETON
Practice Address - State:ND
Practice Address - Zip Code:58061-9740
Practice Address - Country:US
Practice Address - Phone:701-640-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14550593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant