Provider Demographics
NPI:1770971756
Name:JENSEN, MICHAEL (RPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 CARMEL DR APT 12A
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4280
Mailing Address - Country:US
Mailing Address - Phone:925-822-7825
Mailing Address - Fax:
Practice Address - Street 1:3030 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3411
Practice Address - Country:US
Practice Address - Phone:925-822-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist