Provider Demographics
NPI:1851383269
Name:JENSEN, LARRY DEAN (DPM)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11815 SW KING JAMES PLACE
Mailing Address - Street 2:SUITE 60
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224
Mailing Address - Country:US
Mailing Address - Phone:503-639-8107
Mailing Address - Fax:503-639-8108
Practice Address - Street 1:11815 SW KING JAMES PLACE
Practice Address - Street 2:SUITE 60
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-639-8107
Practice Address - Fax:503-639-8108
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00199213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000265Medicaid
OR000265Medicaid
ORR162032Medicare PIN