1770508426 NPI number — DR. GARY L JENSEN

Table of content: DR. GARY L JENSEN (NPI 1770508426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770508426 NPI number — DR. GARY L JENSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
GARY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENSEN
Provider Other First Name:
GARY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1770508426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 NW FIRST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHISHOLM
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55719-1811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-254-4393
Provider Business Mailing Address Fax Number:
218-254-5471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 NW FIRST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHISHOLM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55719-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-254-4393
Provider Business Practice Location Address Fax Number:
218-254-5471
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1610 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2200981 . This is a "MDMA2 MEDICA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "BCMA BCBS PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 411260738 . This is a "PABS CLARITY VISION PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "FIRST FIRST PLAN PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01020509 . This is a "BOIS PREFERRED ONE PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01020509 . This is a "PRE00 UNITED HEALTH PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2200980 . This is a "MCCS1 MEDICA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "ANTHEM BCBS PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "FIRSD FIRST PLAN DISP PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0150730001 . This is a "ADMINISTAR FEDERAL(DMERC), INC." identifier . This identifiers is of the category "OTHER".
  • Identifier: 2100694 . This is a "MDMA3 MEDICA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2200980 . This is a "MDMA1 MEDICA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 411260738 . This is a "BCWP BCBS OF PENN PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "BCMN BCBS PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 524223100 . This is a "MNMA MN MED ASSIST PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "BCMAD BCBS PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD327JE . This is a "COM COMP CARE PIN" identifier . This identifiers is of the category "OTHER".




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