1871596585 NPI number — GERALD E. JENSEN, JR.

Table of content: (NPI 1871596585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871596585 NPI number — GERALD E. JENSEN, JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD E. JENSEN, JR.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1871596585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2633
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAXTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56425-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-822-3736
Provider Business Mailing Address Fax Number:
218-822-3761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6980 FAIRVIEW RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-7836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-822-3736
Provider Business Practice Location Address Fax Number:
218-822-3761
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
218-822-3736

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP 4642 , 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: 555519100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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