Provider Demographics
NPI:1730416629
Name:JENSEN, CRYSTAL M (LMT OR 15194)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LMT OR 15194
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N COLUMBIA RIVER HWY
Mailing Address - Street 2:STE 410
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1299
Mailing Address - Country:US
Mailing Address - Phone:503-410-5623
Mailing Address - Fax:503-410-5672
Practice Address - Street 1:500 N COLUMBIA RIVER HWY
Practice Address - Street 2:STE 410
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1299
Practice Address - Country:US
Practice Address - Phone:503-410-5623
Practice Address - Fax:503-410-5672
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist