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General NPI Number Information
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NPI Number | 1952621872
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Entity Type | Individual
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Provider Name | JEDEDIAH LARS JENSEN DO
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Gender | Male
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Dates
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Enumeration Date | 06/02/2010
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Last Update Date | 12/06/2021
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Provider Practice Location Address
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Address Line | 709 SPRING VALLEY RD
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City | BURLINGTON
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State | WI
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Zip | 53105-7614
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Country | US
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Telephone | 262-971-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 3301 W FOREST HOME AVE
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City | MILWAUKEE
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State | WI
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Zip | 53215-2843
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Country | US
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Telephone | 414-389-2233
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 5101018776
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 5101018776
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 5101018776
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 207RS0010X
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Taxonomy Name | Sports Medicine (Internal Medicine) Physician
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License Number | 73430
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License Number State | WI
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