MEDICARE: HETLEVIA R JENSEN MD PLLC

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	207Q00000X	Family Medicine Physician	23895	OK

General Provider Information

NPI Number	:	1710107529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HETLEVIA R JENSEN MD PLLC

Provider Business Mailing Address
First Line	:	1710 W 3RD ST
Second Line	:	SUITE 103A
City	:	ELK CITY
State	:	OK
Zip	:	73644-5159
Country	:	US
Telephone Number	:	580-225-2269
Fax Number	:	580-225-1504

Provider Business Practice Location Address
First Line	:	1710 W 3RD ST
Second Line	:	SUITE 103A
City	:	ELK CITY
State	:	OK
Zip	:	73644-5159
Country	:	US
Telephone Number	:	580-225-2269
Fax Number	:	580-225-1504

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	HETLEVIA R JENSEN
Credential	:	MD
Telephone Number	:	580-225-2269

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	08/22/2020

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