Healthcare Provider Details

I. General information

NPI: 1164666947
Provider Name (Legal Business Name): STEPHEN EDWARD JENSEN IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 37 BOX 245
APO AE
09459-9998
US

IV. Provider business mailing address

PSC 37 BOX 2841
APO AE
09459-9998
US

V. Phone/Fax

Practice location:
  • Phone: 01638543831
  • Fax:
Mailing address:
  • Phone: 163-854-8214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: