Healthcare Provider Details

I. General information

NPI: 1528020070
Provider Name (Legal Business Name): SUSAN JENSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

IV. Provider business mailing address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-3468
  • Fax: 704-638-3364
Mailing address:
  • Phone: 704-638-3468
  • Fax: 704-638-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberME 63338
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: