Provider Demographics
NPI:1962087403
Name:WILLARD, JENSEN (CRNA)
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 ELK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3741 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7215
Practice Address - Country:US
Practice Address - Phone:801-285-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10643479367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered