1558372615 NPI number — DR. JERRY LEE JENSEN DO

Table of content: DR. JERRY LEE JENSEN DO (NPI 1558372615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558372615 NPI number — DR. JERRY LEE JENSEN DO

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558372615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24239 E CUMBERLAND CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRETE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60417-1854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-672-8940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15525 S PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
SOUTH HOLLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60473-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-331-5100
Provider Business Practice Location Address Fax Number:
708-331-5005
Provider Enumeration Date:
08/11/2006

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: 207Q00000X , with the licence number:  036071680 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0031603768 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036071680 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14D0913083 . This is a "CLIA NUMBER" identifier . This identifiers is of the category "OTHER".




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