Healthcare Provider Details

I. General information

NPI: 1184602351
Provider Name (Legal Business Name): MARK H JENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 90 N STE 103
AMERICAN FORK UT
84003-2954
US

IV. Provider business mailing address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

V. Phone/Fax

Practice location:
  • Phone: 801-852-9560
  • Fax: 801-852-9559
Mailing address:
  • Phone: 801-374-9625
  • Fax: 801-374-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number47680
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47680
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number7903019-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number7903019-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: