Healthcare Provider Details

I. General information

NPI: 1518028349
Provider Name (Legal Business Name): DONALD MILTON JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W. HARRISON STREET SUITE 158
CHICAGO IL
60612
US

IV. Provider business mailing address

1725 W. HARRISON STREET SUITE 158
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-8910
  • Fax:
Mailing address:
  • Phone: 312-942-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036048965
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number036.048965
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036.048965
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.048965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: