Provider Demographics
NPI:1528150927
Name:JENSEN, SUSAN E (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:E
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5781 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-5426
Practice Address - Country:US
Practice Address - Phone:541-654-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003480363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10003480OtherMEDICAL LICENSE
WA0156622OtherL & I PROVIDER #
WAS61508Medicare UPIN
WAG8851535Medicare PIN