Healthcare Provider Details

I. General information

NPI: 1386739837
Provider Name (Legal Business Name): KEVIN NEAL JENSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 E COUNTRY FIELD CIR STE B
WASILLA AK
99654-6659
US

IV. Provider business mailing address

3750 E COUNTRY FIELD CIR STE B
WASILLA AK
99654-6659
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-1410
  • Fax:
Mailing address:
  • Phone: 907-373-1410
  • Fax: 907-373-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number107880
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: