Provider Demographics
NPI:1770684318
Name:CHRISTENSEN, JERROLD W (PA-C)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:W
Last Name:CHRISTENSEN
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 1:406 SUNRISE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-536-2500
Mailing Address - Fax:
Practice Address - Street 1:3160 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-733-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11633207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA129961OtherHEALTH NET
CA5991534OtherAETNA
CA90080941OtherPACIFICARE
CAPA11633OtherBLUE CROSS
CA461128OtherINTERPLAN
CA2042467OtherCIGNA
CA1750253OtherGREAT WEST
CA2680941OtherUNITED HEALTHCARE
CAPA11633Medicaid
CAPA11633OtherBLUE CROSS
CA0PA116330Medicare ID - Type Unspecified