Provider Demographics
NPI:1366643777
Name:TAHIRIH JENSEN D.O. PC
Entity Type:Organization
Organization Name:TAHIRIH JENSEN D.O. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAHIRIH
Authorized Official - Middle Name:THEONE
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:D,O
Authorized Official - Phone:928-282-7322
Mailing Address - Street 1:PO BOX 21450
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86341-1450
Mailing Address - Country:US
Mailing Address - Phone:928-282-7322
Mailing Address - Fax:928-282-7350
Practice Address - Street 1:6050 HIGHWAY 179 STE 5
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-7986
Practice Address - Country:US
Practice Address - Phone:928-282-7322
Practice Address - Fax:928-282-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ882797Medicaid
AZI13937Medicare UPIN
AZ882797Medicaid