Provider Demographics
NPI:1528265832
Name:JENSEN, JACLYN M (DDS)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1197 A SOUTH COLUMBIA ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-775-4751
Mailing Address - Fax:701-746-4931
Practice Address - Street 1:1197 A SOUTH COLUMBIA ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-775-4751
Practice Address - Fax:701-746-4931
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist