Basic Information
Provider Information | |||||||||
NPI: | 1366534273 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENSEN | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2450 RIVERSIDE AVE S | ||||||||
Address2: | 2 WEST | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 55455 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122738700 | ||||||||
FaxNumber: | 6122738787 | ||||||||
Practice Location | |||||||||
Address1: | 2450 RIVERSIDE AVE SE | ||||||||
Address2: | 2A WEST | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554541450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122738700 | ||||||||
FaxNumber: | 6122738787 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 01/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 20799 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | HP22358 | 01 | MN | HEALTH PARTNERS | OTHER | 1009157 | 01 | MN | PREFERRED ONE | OTHER | 095293100 | 05 | MN |   | MEDICAID | 102784 | 01 | MN | U CARE | OTHER | 1514059 | 01 | MN | MEDICA-CHOICE | OTHER | 260026114 | 01 | MN | RR MEDICARE | OTHER | 768179 | 01 |   | ARAZ | OTHER | 8D926JE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 082701 | 01 | MN | FAIRVIEW | OTHER | 1514059 | 01 | MN | MEDICA-PRIMARY | OTHER |