Healthcare Provider Details

I. General information

NPI: 1144239054
Provider Name (Legal Business Name): KRISTOPHER L JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 COMMERCIAL CT UNIT 300
VENICE FL
34292-1667
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-261-0010
  • Fax: 941-261-0011
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0420009208
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME140656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: