Provider Demographics
NPI:1821072828
Name:JENSEN, NATISHA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NATISHA
Middle Name:NICOLE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NATISHA
Other - Middle Name:NICOLE PHILLIPS
Other - Last Name:BUSICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 SUPERIOR AVE STE 200G
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3664
Mailing Address - Country:US
Mailing Address - Phone:949-791-6767
Mailing Address - Fax:949-791-6768
Practice Address - Street 1:510 SUPERIOR AVE STE 200G
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3664
Practice Address - Country:US
Practice Address - Phone:949-791-6767
Practice Address - Fax:949-791-6768
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34527208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0104OtherJOHN DEERE
IA16957OtherBLUE CROSS BLUE SHIELD
IA246930OtherMIDLANDS CHOICE
IA5266486Medicaid
IAH73101Medicare UPIN
IA5266486Medicaid