Provider Demographics
NPI:1306025549
Name:JENSEN, EDWIN (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 LARK LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-3215
Mailing Address - Country:US
Mailing Address - Phone:856-428-1506
Mailing Address - Fax:
Practice Address - Street 1:1736 LARK LN
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-3215
Practice Address - Country:US
Practice Address - Phone:856-428-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02501900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1008868OtherHORIZON NEW JERSEY HEALTH
NJ32866OtherAMERIGROUP
NJ01000075601OtherAMERICHOICE
NJ0106612001OtherAMERIHEALTH
NJ2787008Medicaid
NJD77302Medicare UPIN
NJ2787008Medicaid