Provider Demographics
NPI:1518079193
Name:JENSEN, MARK JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
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 1:401 N. WEST STREET
Mailing Address - Street 2:SUITE 113
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603
Mailing Address - Country:US
Mailing Address - Phone:919-828-5669
Mailing Address - Fax:919-828-5676
Practice Address - Street 1:401 N. WEST STREET
Practice Address - Street 2:SUITE 113
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603
Practice Address - Country:US
Practice Address - Phone:919-828-5669
Practice Address - Fax:919-828-5676
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2427111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890834TMedicaid
NC890834TMedicaid