Basic Information
| Provider Information | |||||||||
| NPI: | 1871553255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066430405 | ||||||||
| FaxNumber: | 9066431553 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 OSCEOLA ST | ||||||||
| Address2: | |||||||||
| City: | LAURIUM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499132134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063376560 | ||||||||
| FaxNumber: | 9063376582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 5101014312 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207Q00000X | 5101014312 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1871553255 | 01 | WI | WI MEDICAID | OTHER | P01393231 | 01 | MI | RAILROAD MEDICARE | OTHER | 1871553255 | 05 | MI | MEDICAID |