MEDICARE: JEN MED PROF LLC

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	1034	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	S2312	OTHER	SD	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	142389900	OTHER	SD	OWCP PROVIDER
2	42339	OTHER	SD	RADIATION MEDICAL LICENSE
3	14172-1	OTHER	SD	FAA LICENSE NUMBER
4	5602360	OTHER	SD	TITLE 19
6	1034	OTHER	SD	PHYSICIAN'S LICENSE
7	43D0408177	OTHER	SD	CLIA LAB

General Provider Information

NPI Number	:	1528020229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEN MED PROF LLC

Provider Business Mailing Address
First Line	:	1010 BALLPARK RD
Second Line	:	SUITE 2
City	:	STURGIS
State	:	SD
Zip	:	57785-2364
Country	:	US
Telephone Number	:	605-347-3684
Fax Number	:	605-347-0083

Provider Business Practice Location Address
First Line	:	1010 BALLPARK RD
Second Line	:	SUITE 2
City	:	STURGIS
State	:	SD
Zip	:	57785-2364
Country	:	US
Telephone Number	:	605-347-3684
Fax Number	:	605-347-0083

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	GEORGE W. JENTER
Credential	:	D.O.
Telephone Number	:	605-347-3684

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	03/07/2023

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Directions to “JEN MED PROF LLC ” Practice Location

Language	Start Address	Practice Location

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