Healthcare Provider Details

I. General information

NPI: 1255887675
Provider Name (Legal Business Name): MR. JOSEPH JENSEN III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 N POPE ST
SILVER CITY NM
88061-5150
US

IV. Provider business mailing address

907 N POPE ST
SILVER CITY NM
88061-5150
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1976
  • Fax: 575-538-2339
Mailing address:
  • Phone: 575-388-1976
  • Fax: 575-538-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number16-1943
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: