Provider Demographics
NPI:1922001338
Name:JENSEN, JAN VENNELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:VENNELL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W 39TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2805
Mailing Address - Country:US
Mailing Address - Phone:308-865-2760
Mailing Address - Fax:308-865-2769
Practice Address - Street 1:411 W. 39TH ST.
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845
Practice Address - Country:US
Practice Address - Phone:308-865-2760
Practice Address - Fax:308-865-2769
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12529207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47054533500Medicaid
B67681Medicare UPIN
NE47054533500Medicaid