Healthcare Provider Details

I. General information

NPI: 1326230236
Provider Name (Legal Business Name): DANIEL LORAN JENSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27500 HOOVER RD STE 100
WARREN MI
48093-4586
US

IV. Provider business mailing address

PO BOX 6739195
DETROIT MI
48267-3937
US

V. Phone/Fax

Practice location:
  • Phone: 586-754-2558
  • Fax:
Mailing address:
  • Phone: 810-720-5715
  • Fax: 810-732-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5101015155
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: