Healthcare Provider Details

I. General information

NPI: 1366534273
Provider Name (Legal Business Name): JONATHAN B JENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE SE 2A WEST
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE S 2 WEST
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8700
  • Fax: 612-273-8787
Mailing address:
  • Phone: 612-273-8700
  • Fax: 612-273-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20799
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: