Provider Demographics
NPI:1639752215
Name:JENSON, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JENSON
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 1:3408 N COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-7402
Mailing Address - Country:US
Mailing Address - Phone:801-718-9228
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:801-718-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty