Healthcare Provider Details

I. General information

NPI: 1437199361
Provider Name (Legal Business Name): KIRK B JENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GARFIELD AVE
PARKERSBURG WV
26101-5340
US

IV. Provider business mailing address

PO BOX 75113
BALTIMORE MD
21275-5113
US

V. Phone/Fax

Practice location:
  • Phone: 304-424-2111
  • Fax: 904-346-0113
Mailing address:
  • Phone: 304-422-1666
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21814
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: