Provider Demographics
NPI:1568446227
Name:JENSEN, KELLY ELIZABETH CLARK (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH CLARK
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:E
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4745 ARAPAHOE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1080
Mailing Address - Country:US
Mailing Address - Phone:303-938-4710
Mailing Address - Fax:
Practice Address - Street 1:4745 ARAPAHOE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1080
Practice Address - Country:US
Practice Address - Phone:303-938-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41897207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO513678Medicare ID - Type Unspecified
H95657Medicare UPIN