Healthcare Provider Details

I. General information

NPI: 1962128272
Provider Name (Legal Business Name): MAX BENJAMIN JENSEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 WYOMING BLVD NE
ALBUQUERQUE NM
87109-3167
US

IV. Provider business mailing address

1449 ADAMS ST NE
ALBUQUERQUE NM
87110-5046
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6600
  • Fax:
Mailing address:
  • Phone: 503-830-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70389
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: