Provider Demographics
NPI:1346453990
Name:JENSEN, CANDICE MICHELLE (MD, PLLC)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:MICHELLE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 S AVE A
Mailing Address - Street 2:STE 3
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7173
Mailing Address - Country:US
Mailing Address - Phone:928-344-3250
Mailing Address - Fax:928-344-3253
Practice Address - Street 1:2503 S AVE A
Practice Address - Street 2:STE 3
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7173
Practice Address - Country:US
Practice Address - Phone:928-344-3250
Practice Address - Fax:928-344-3253
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100498208600000X
AZ38206208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1004980Medicaid
AZ340763Medicaid
AZZ148161OtherMEDICARE PTAN
CA0A1004980Medicaid