Provider Demographics
NPI:1730413816
Name:JENSEN, ERIN MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 HIMALAYAS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-732-9576
Mailing Address - Fax:
Practice Address - Street 1:859 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4078
Practice Address - Country:US
Practice Address - Phone:909-732-9576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant