Healthcare Provider Details

I. General information

NPI: 1164585154
Provider Name (Legal Business Name): SHANE D JENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

PO BOX 936
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 210-539-9582
  • Fax:
Mailing address:
  • Phone: 757-451-6266
  • Fax: 757-451-6251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101262983
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberQ4994
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: