Provider Demographics
NPI:1134291438
Name:JENSEN GRANVILLE, DENIESE ELAINE (DPM)
Entity Type:Individual
Prefix:
First Name:DENIESE
Middle Name:ELAINE
Last Name:JENSEN GRANVILLE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:DENIESE
Other - Middle Name:E
Other - Last Name:GRANVILLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:55 S STATE ST STE 3220
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3975
Mailing Address - Country:US
Mailing Address - Phone:503-635-7742
Mailing Address - Fax:503-635-8495
Practice Address - Street 1:55 S STATE ST STE 3220
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3975
Practice Address - Country:US
Practice Address - Phone:503-635-7742
Practice Address - Fax:503-635-8495
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00223213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR038377Medicaid
U24944Medicare UPIN
OR6313720001Medicare NSC
OR038377Medicaid