MEDICARE: DEREK JENSEN

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	390200000X	Student in an Organized Health Care Education/Training Program	0	FL
2	2255A2300X	Athletic Trainer	0506408	NV
3	2255A2300X	Athletic Trainer	0	FL

General Provider Information

NPI Number	:	1669872420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK JENSEN

Provider Business Mailing Address
First Line	:	5305 REBECCA RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-1735
Country	:	US
Telephone Number	:	702-287-8474
Fax Number	:

Provider Business Practice Location Address
First Line	:	5305 REBECCA RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-1735
Country	:	US
Telephone Number	:	702-287-8474
Fax Number	:

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

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	12/01/2021

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