Individual
MALLORY ROSE JENSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6141 N CICERO AVE, CHICAGO, IL 60646-4303
(224) 364-2273
(847) 663-8290
Mailing address
6141 N CICERO AVE, CHICAGO, IL 60646-4303
(224) 364-2273
(847) 663-8290
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085004404
IL
363AM0700X
Medical Physician Assistant
085.004404
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085.004404
ILLINOIS STATE LICENSE NUMBER
IL
01
—
385003174
ILLINOIS CONTROLLED SUBSTANCE LICENSE
IL
Enumeration date
09/21/2012
Last updated
08/23/2021
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