Provider Demographics
NPI:1164666947
Name:JENSEN, STEPHEN EDWARD (IDMT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:JENSEN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 37
Mailing Address - Street 2:BOX 2841
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09459-9998
Mailing Address - Country:US
Mailing Address - Phone:163-854-8214
Mailing Address - Fax:
Practice Address - Street 1:PSC 37
Practice Address - Street 2:BOX 245
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09459-9998
Practice Address - Country:US
Practice Address - Phone:0163-854-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians