Basic Information
| Provider Information | |||||||||
| NPI: | 1114993441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026292055 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4444P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3004444 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000600371 | 01 | KY | ANTHEM | OTHER |