Basic Information
| Provider Information | |||||||||
| NPI: | 1992729230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581024539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581024539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 48922 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 11822 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | MD125825 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 51933-020 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 15606 | 05 | ND | MEDICAID | P00405196 | 01 | MN | MEDICARE RAILROAD | OTHER | 487480000 | 05 | MN | MEDICAID |