Healthcare Provider Details

I. General information

NPI: 1134121312
Provider Name (Legal Business Name): CHRISTIAN EDWARD JENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9309 CORKELL RD
DENTON MD
21629
US

IV. Provider business mailing address

PO BOX 690
DENTON MD
21629-0690
US

V. Phone/Fax

Practice location:
  • Phone: 410-479-2605
  • Fax: 410-479-3354
Mailing address:
  • Phone: 410-479-2605
  • Fax: 410-479-3354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD14664
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: