Provider Demographics
NPI:1689927964
Name:JENSEN, BRIAN THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W VAN BUREN ST STE T
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1307
Mailing Address - Country:US
Mailing Address - Phone:623-932-9905
Mailing Address - Fax:623-932-6901
Practice Address - Street 1:501 W VAN BUREN ST STE T
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1307
Practice Address - Country:US
Practice Address - Phone:623-932-9905
Practice Address - Fax:623-932-6901
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5296207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine