Provider Demographics
NPI:1942209184
Name:JENSEN, KRISTIAN HALE (PAC)
Entity Type:Individual
Prefix:MR
First Name:KRISTIAN
Middle Name:HALE
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-807-1266
Mailing Address - Fax:317-859-4269
Practice Address - Street 1:679 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1049
Practice Address - Country:US
Practice Address - Phone:317-890-2000
Practice Address - Fax:317-859-7220
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001335363A00000X
NC102163363A00000X
IN10002986A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S40866Medicare UPIN
ILK09911Medicare ID - Type Unspecified