MEDICARE: SUSANNAH JENSEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital		IL

General Provider Information

NPI Number	:	1194977827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNAH JENSEN MD

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE STE 5303
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1718
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 RIDGE AVE STE 5303
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1718
Country	:	US
Telephone Number	:	847-570-1463
Fax Number	:	847-578-8647

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2008
Last Update Date	:	04/08/2015

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