Healthcare Provider Details

I. General information

NPI: 1598745002
Provider Name (Legal Business Name): JONATHAN EDWARD JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W RAVINE RD
KINGSPORT TN
37660-3837
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-224-4000
  • Fax:
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number33738
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number042-0014522
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number69824
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: