Provider Demographics
NPI:1619966785
Name:JEBSEN, DARRELL A (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:A
Last Name:JEBSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-1888
Mailing Address - Country:US
Mailing Address - Phone:641-752-5469
Mailing Address - Fax:641-844-2205
Practice Address - Street 1:312 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-1888
Practice Address - Country:US
Practice Address - Phone:641-752-5469
Practice Address - Fax:641-844-2205
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0202119Medicaid
IA0202119Medicaid