Provider Demographics
NPI:1770552846
Name:JENSEN, JOHANNA M (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 12TH AVE RD
Mailing Address - Street 2:STE A
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7713
Mailing Address - Country:US
Mailing Address - Phone:208-467-4406
Mailing Address - Fax:208-467-4450
Practice Address - Street 1:1615 12TH AVE RD
Practice Address - Street 2:STE A
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-7713
Practice Address - Country:US
Practice Address - Phone:208-467-4406
Practice Address - Fax:208-467-4450
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9011207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0638840001OtherDMERC
ID806911600Medicaid
ID000010147359OtherREGENCE BLUE SHIELD OF ID
ID70862OtherBLUE CROSS OF IDAHO
ID70862OtherBLUE CROSS OF IDAHO
ID806911600Medicaid