Healthcare Provider Details

I. General information

NPI: 1952798167
Provider Name (Legal Business Name): DREW JENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2015
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W MAIN ST
CHARLOTTESVILLE VA
22903-2824
US

IV. Provider business mailing address

505 NE 87TH AVE STE 210
VANCOUVER WA
98664-1988
US

V. Phone/Fax

Practice location:
  • Phone: 434-982-6100
  • Fax: 434-982-0747
Mailing address:
  • Phone: 360-828-5396
  • Fax: 360-828-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD61036205
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: