Healthcare Provider Details

I. General information

NPI: 1770684540
Provider Name (Legal Business Name): MICHAEL G JENSON PAC CPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6585 SOUTH YALE SUITE 1110
TULSA OK
74136
US

IV. Provider business mailing address

4807 E 91ST ST LB003
TULSA OK
74137-2841
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-7246
  • Fax: 918-502-7250
Mailing address:
  • Phone: 918-502-7246
  • Fax: 918-502-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number538
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: