Provider Demographics
NPI:1306492897
Name:JENSEN, BLANCHE COLEMAN
Entity type:Individual
Prefix:
First Name:BLANCHE
Middle Name:COLEMAN
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 1:6848 MAHOGANY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5360
Mailing Address - Country:US
Mailing Address - Phone:910-868-7195
Mailing Address - Fax:
Practice Address - Street 1:6848 MAHOGANY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-5360
Practice Address - Country:US
Practice Address - Phone:910-868-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider