Provider Demographics
NPI:1033174982
Name:JESSEN, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:JESSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1326 ANDREA ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3334
Mailing Address - Country:US
Mailing Address - Phone:270-781-1588
Mailing Address - Fax:270-781-1598
Practice Address - Street 1:1326 ANDREA ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3334
Practice Address - Country:US
Practice Address - Phone:270-781-1588
Practice Address - Fax:270-781-1598
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29379208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64293798Medicaid
KYF55831Medicare UPIN
KYK096120Medicare PIN