Provider Demographics
NPI:1528108909
Name:JENSEN, GAY M (RDH)
Entity type:Individual
Prefix:
First Name:GAY
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 PACIFIC AVE SE STE A6 PMB 170
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2177
Mailing Address - Country:US
Mailing Address - Phone:360-791-9969
Mailing Address - Fax:
Practice Address - Street 1:3430 PACIFIC AVE SE STE A6 PMB 170
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2177
Practice Address - Country:US
Practice Address - Phone:360-791-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH20000537124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1738790OtherUNITED CONCORDIA
WA5900287Medicaid
WA5900287Medicare ID - Type UnspecifiedDSHS