Provider Demographics
NPI:1295895753
Name:REGINA M JENSEN MD PA
Entity type:Organization
Organization Name:REGINA M JENSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-343-8411
Mailing Address - Street 1:4536 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405
Mailing Address - Country:US
Mailing Address - Phone:910-343-8411
Mailing Address - Fax:910-343-8414
Practice Address - Street 1:4536 TECHNOLOGY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405
Practice Address - Country:US
Practice Address - Phone:910-343-8411
Practice Address - Fax:910-343-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F54309Medicare UPIN
SC2330974Medicare PIN