Provider Demographics
NPI:1255887675
Name:JENSEN, JOSEPH III
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:JENSEN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 N POPE ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5150
Mailing Address - Country:US
Mailing Address - Phone:575-388-1976
Mailing Address - Fax:575-538-2339
Practice Address - Street 1:907 N POPE ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5150
Practice Address - Country:US
Practice Address - Phone:575-388-1976
Practice Address - Fax:575-538-2339
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16-1943252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000D1036Medicaid
NM99657Medicaid