Provider Demographics
NPI:1609819341
Name:JOHN M JENSEN
Entity Type:Organization
Organization Name:JOHN M JENSEN
Other - Org Name:WRIGHTSVILLE FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLO PRACTICE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:717-252-1575
Mailing Address - Street 1:900 HELLAM ST
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17368-1019
Mailing Address - Country:US
Mailing Address - Phone:717-252-1575
Mailing Address - Fax:717-252-2321
Practice Address - Street 1:900 HELLAM ST
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17368-1019
Practice Address - Country:US
Practice Address - Phone:717-252-1575
Practice Address - Fax:717-252-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S004334L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
02300000OtherCAPITAL BLUE CROSS
PA0006437080004Medicaid
C29942Medicare UPIN
PA0006437080004Medicaid