Provider Demographics
NPI:1457322703
Name:JENSEN, MICHAEL J (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CROSS ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5406
Mailing Address - Country:US
Mailing Address - Phone:253-876-8111
Mailing Address - Fax:253-876-8211
Practice Address - Street 1:202 CROSS ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5406
Practice Address - Country:US
Practice Address - Phone:253-876-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1469363AM0700X
WAPA60055107363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069430AMedicaid
OKP00363323OtherMEDICARE RAILROAD
OK200069430AMedicaid
OK248534902Medicare ID - Type Unspecified