Healthcare Provider Details

I. General information

NPI: 1205914157
Provider Name (Legal Business Name): MARY E JENSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR FL 4
CHARLOTTESVILLE VA
22911-4668
US

IV. Provider business mailing address

PO BOX 79777
BALTIMORE MD
21279-0777
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-8960
  • Fax: 434-654-8961
Mailing address:
  • Phone: 434-654-7794
  • Fax: 434-654-8961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101036767
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0101036767
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: