MEDICARE: MR. JOSEPH JENSEN III

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	252Y00000X	Early Intervention Provider Agency	16-1943	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255887675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH JENSEN III

Provider Business Mailing Address
First Line	:	907 N POPE ST
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-5150
Country	:	US
Telephone Number	:	575-388-1976
Fax Number	:	575-538-2339

Provider Business Practice Location Address
First Line	:	907 N POPE ST
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-5150
Country	:	US
Telephone Number	:	575-388-1976
Fax Number	:	575-538-2339

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

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	08/26/2016

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