Healthcare Provider Details

I. General information

NPI: 1972921005
Provider Name (Legal Business Name): ANDREW JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2014
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 B AVE
ZUNI NM
87327
US

IV. Provider business mailing address

1115 E 20TH ST
SIOUX FALLS SD
57105-1013
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-4431
  • Fax: 505-782-4502
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10447
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: