Healthcare Provider Details

I. General information

NPI: 1023129996
Provider Name (Legal Business Name): BLAINE S. JENSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 W HWY 60
SUPERIOR AZ
85273-2647
US

IV. Provider business mailing address

1134 W HWY 60
SUPERIOR AZ
85173-2647
US

V. Phone/Fax

Practice location:
  • Phone: 520-689-2423
  • Fax: 520-689-5237
Mailing address:
  • Phone: 520-689-2423
  • Fax: 928-425-3859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2322
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: