=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609819341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN M JENSEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 HELLAM ST
-----------------------------------------------------
City | WRIGHTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17368-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-252-1575
-----------------------------------------------------
Fax | 717-252-2321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 HELLAM ST
-----------------------------------------------------
City | WRIGHTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17368-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-252-1575
-----------------------------------------------------
Fax | 717-252-2321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLO PRACTICE PHYSICIAN
-----------------------------------------------------
Name | DR. JOHN MARTIN JENSEN JR.
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 717-252-1575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0S004334L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------