Basic Information
| Provider Information | |||||||||
| NPI: | 1164707477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | MIKELL | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356280612 | ||||||||
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| Practice Location | |||||||||
| Address1: | 960 N DIXIE DOWNS RD | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356280612 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 10/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.