Provider Demographics
NPI:1548408149
Name:JENSEN, BENJAMIN BENONI (DC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BENONI
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 W 200 N APT 4
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3841
Mailing Address - Country:US
Mailing Address - Phone:435-770-4043
Mailing Address - Fax:
Practice Address - Street 1:944 S HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5436
Practice Address - Country:US
Practice Address - Phone:435-755-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7224219-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor