Provider Demographics
NPI:1346639648
Name:JENSON, JOSEPH
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:JENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 E 1150 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1316 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-4203
Practice Address - Country:US
Practice Address - Phone:435-789-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-10
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8351283-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist