Healthcare Provider Details

I. General information

NPI: 1528020229
Provider Name (Legal Business Name): JEN MED PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 BALLPARK RD SUITE 2
STURGIS SD
57785-2364
US

IV. Provider business mailing address

1010 BALLPARK RD SUITE 2
STURGIS SD
57785-2364
US

V. Phone/Fax

Practice location:
  • Phone: 605-347-3684
  • Fax: 605-347-0083
Mailing address:
  • Phone: 605-347-3684
  • Fax: 605-347-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1034
License Number StateSD

VIII. Authorized Official

Name: GEORGE W. JENTER
Title or Position: OWNER/OPERATOR
Credential: D.O.
Phone: 605-347-3684