Provider Demographics
NPI:1801345541
Name:JENSEN, MARK CHARLES (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440-1220
Mailing Address - Country:US
Mailing Address - Phone:231-672-4663
Mailing Address - Fax:231-672-4958
Practice Address - Street 1:8219 W SHELBY RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-9560
Practice Address - Country:US
Practice Address - Phone:310-850-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N79320Medicare PIN