Provider Demographics
NPI:1770684540
Name:JENSON, MICHAEL G (PAC CPP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:JENSON
Suffix:
Gender:M
Credentials:PAC CPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 E 91ST ST
Mailing Address - Street 2:LB003
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2841
Mailing Address - Country:US
Mailing Address - Phone:918-502-7246
Mailing Address - Fax:918-502-7250
Practice Address - Street 1:6585 SOUTH YALE
Practice Address - Street 2:SUITE 1110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-502-7246
Practice Address - Fax:918-502-7250
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDA8285OtherMEDICARE RAILROAD
OK200070240AMedicaid
OK680535868002OtherBLUE CROSS BLUE SHIELD
OK200070240AMedicaid
OKDA8285OtherMEDICARE RAILROAD