Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 8963761-1204 | UT |
N | 207ND0900X | Dermatopathologist | 8963761-1204 | UT |
NPI | 1619294337 |
---|---|
Provider Name | Jesse David Jensen |
First Address | West Valley City, UT 84120-2076 |
Second Address | Tooele, UT 84074-3413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2010 |
Last Update Date | 07/03/2016 |