Provider Demographics
NPI:1558372615
Name:JENSEN, JERRY LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24239 E CUMBERLAND CT
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1854
Mailing Address - Country:US
Mailing Address - Phone:708-672-8940
Mailing Address - Fax:
Practice Address - Street 1:15525 S PARK AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1308
Practice Address - Country:US
Practice Address - Phone:708-331-5100
Practice Address - Fax:708-331-5005
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031603768OtherBLUE CROSS
IL036071680Medicaid
14D0913083OtherCLIA NUMBER
IL0031603768OtherBLUE CROSS
14D0913083OtherCLIA NUMBER