Provider Demographics
NPI:1811971005
Name:JENSEN, DIANA ALTHEA (MD)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:ALTHEA
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:ALTHEA
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:40 LAMBERT ST
Mailing Address - Street 2:SUITE 411, STAUNTON MEDICAL CENTER
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-2446
Mailing Address - Country:US
Mailing Address - Phone:540-886-0827
Mailing Address - Fax:540-886-6360
Practice Address - Street 1:40 LAMBERT ST
Practice Address - Street 2:SUITE 411, STAUNTON MEDICAL CENTER
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-2446
Practice Address - Country:US
Practice Address - Phone:540-886-0827
Practice Address - Fax:540-886-6360
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046988208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA038612OtherBCBS
VA5604249Medicaid
VA2114197OtherMAMSI
F53333Medicare UPIN
VA5604249Medicaid