Provider Demographics
NPI:1639288715
Name:JENSEN, CHAD RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RYAN
Last Name:JENSEN
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-779-6200
Mailing Address - Fax:
Practice Address - Street 1:2400 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-786-7500
Practice Address - Fax:801-737-9531
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62664731205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000059577Medicare PIN
000059578Medicare PIN
000059572Medicare PIN
000059573Medicare PIN
000059574Medicare PIN
000059576Medicare PIN
000059575Medicare PIN
UT000063334Medicare PIN