Provider Demographics
NPI:1932233392
Name:GRAVERSEN, JENS FRANCIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JENS
Middle Name:FRANCIS
Last Name:GRAVERSEN
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-399-6167
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:1002 JEFFERSON ST.
Practice Address - Street 2:SUITE 450
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4306
Practice Address - Country:US
Practice Address - Phone:601-428-0438
Practice Address - Fax:601-425-5553
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200326208800000X
MS17542208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04274856Medicaid
LA1598551Medicaid
LAI38062Medicare UPIN
MS302I341774Medicare Oscar/Certification
LA1598551Medicaid