Provider Demographics
NPI:1710107529
Name:HETLEVIA R JENSEN MD PLLC
Entity Type:Organization
Organization Name:HETLEVIA R JENSEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HETLEVIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-225-2269
Mailing Address - Street 1:1710 W 3RD ST
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-5159
Mailing Address - Country:US
Mailing Address - Phone:580-225-2269
Mailing Address - Fax:580-225-1504
Practice Address - Street 1:1710 W 3RD ST
Practice Address - Street 2:SUITE 103A
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5159
Practice Address - Country:US
Practice Address - Phone:580-225-2269
Practice Address - Fax:580-225-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty