=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649201419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. BRUCE LAMONT JENSEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 07/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1646 ELMIRA STREET
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-399-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11059 E. BETHANY DRIVE
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-617-2300
-----------------------------------------------------
Fax | 303-617-2365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 16467
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------