Provider Demographics
NPI:1659366342
Name:JENSEN, TRAVIS STEVEN (DPM)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:STEVEN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12361 W BOLA DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:623-584-5626
Mailing Address - Fax:623-584-8998
Practice Address - Street 1:12361 W BOLA DR
Practice Address - Street 2:STE 100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-584-5626
Practice Address - Fax:623-584-8998
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16005134213E00000X
AZ665213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL96004401Medicaid
IL0581740001OtherDMERC
IL60010789OtherBCBS
AZ1659366342OtherBC/BS
AZ118419OtherRAILROAD MEDICARE
IL96004401Medicaid
AZ0321470001Medicare NSC
AZ1659366342OtherBC/BS