Provider Demographics
NPI:1437199361
Name:JENSEN, KIRK B (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:B
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75113
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5113
Mailing Address - Country:US
Mailing Address - Phone:304-422-1666
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2111
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21814207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004341Medicaid
WVA52200Medicare UPIN
WVJE4177611Medicare ID - Type Unspecified