Provider Demographics
NPI:1699174706
Name:JENSEN, MICHELLE (RD, CDE)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 S FORT APACHE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5613
Mailing Address - Country:US
Mailing Address - Phone:702-475-4007
Mailing Address - Fax:702-475-4060
Practice Address - Street 1:6040 S FORT APACHE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148
Practice Address - Country:US
Practice Address - Phone:702-475-4007
Practice Address - Fax:702-475-4060
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32302DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered