Basic Information
Provider Information | |||||||||
NPI: | 1881822583 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENSEN | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | EVANS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 13TH AVE S STE 103 | ||||||||
Address2: |   | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 594054300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4064552970 | ||||||||
FaxNumber: | 4064552971 | ||||||||
Practice Location | |||||||||
Address1: | 400 13TH AVE S STE 102 | ||||||||
Address2: |   | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 594054300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738824141 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2009 | ||||||||
LastUpdateDate: | 02/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 30013 | MT | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 2009017496 | MO | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.