MEDICARE: MATTHEW KRUEGER JENSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	72686	WI

General Provider Information

NPI Number	:	1063917243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW KRUEGER JENSON MD

Provider Business Mailing Address
First Line	:	124 SIEGLER ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-2636
Country	:	US
Telephone Number	:	920-494-9661
Fax Number	:	920-496-3792

Provider Business Practice Location Address
First Line	:	124 SIEGLER ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-2636
Country	:	US
Telephone Number	:	920-494-9661
Fax Number	:	920-496-3792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	08/10/2021

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