Provider Demographics
NPI:1902912827
Name:JENSEN, ELIZABETH (APRN, DNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:APRN, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SIMSBURY RD STE 12B
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3735
Mailing Address - Country:US
Mailing Address - Phone:860-674-0111
Mailing Address - Fax:860-674-5406
Practice Address - Street 1:120 SIMSBURY RD STE B
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3735
Practice Address - Country:US
Practice Address - Phone:860-674-0111
Practice Address - Fax:860-674-5406
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002310364SW0102X
CT000189363LX0001X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004205440Medicaid
P05842Medicare UPIN
420000064Medicare ID - Type Unspecified