Provider Demographics
NPI:1922099324
Name:JENSON, KRAIG KRUEGER (MD)
Entity Type:Individual
Prefix:DR
First Name:KRAIG
Middle Name:KRUEGER
Last Name:JENSON
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 1:3408 N COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-7402
Mailing Address - Country:US
Mailing Address - Phone:801-373-4854
Mailing Address - Fax:801-224-2667
Practice Address - Street 1:1385 E 750 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5480
Practice Address - Country:US
Practice Address - Phone:801-224-5200
Practice Address - Fax:801-224-2667
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164938-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005786201Medicare PIN