Provider Demographics
NPI:1740360635
Name:JENSEN, GERALD D (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:D
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 1:2600 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4379
Mailing Address - Country:US
Mailing Address - Phone:612-706-2900
Mailing Address - Fax:
Practice Address - Street 1:2600 39TH AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4379
Practice Address - Country:US
Practice Address - Phone:612-706-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN80000361Medicare ID - Type Unspecified
MNA94015Medicare UPIN