Provider Demographics
NPI:1487638482
Name:JENSEN, BRIAN LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3049 MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-341-2644
Mailing Address - Fax:715-341-2644
Practice Address - Street 1:3049 MICHIGAN AVENUE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481
Practice Address - Country:US
Practice Address - Phone:715-341-2644
Practice Address - Fax:715-341-2644
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2412012111N00000X
WI2412-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350053550OtherRAILROAD MEDICARE
WI38839400Medicaid
WI350053550OtherRAILROAD MEDICARE
WI000035373Medicare ID - Type Unspecified