Healthcare Provider Details

I. General information

NPI: 1033106497
Provider Name (Legal Business Name): SCOTT MILTON JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6682 LOWER RIDGE DR
LAKESIDE AZ
85929-5064
US

IV. Provider business mailing address

6682 LOWER RIDGE DR
LAKESIDE AZ
85929-5064
US

V. Phone/Fax

Practice location:
  • Phone: 928-224-4270
  • Fax: 928-212-9017
Mailing address:
  • Phone: 928-224-4270
  • Fax: 928-212-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20652
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCDR.0000986
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number120685509-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1348-20
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28925
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: