Provider Demographics
NPI:1215292669
Name:JENSEN, JACOB DARRELL (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DARRELL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNMMG
Mailing Address - Street 2:933 BRADBURY SE, SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:UNM DEPARTMENT OF EMERGENCY MEDICINE-MSC11 6025
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065738207P00000X
IDO-1304207P00000X
NMA-2047-17207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDO-1304OtherSTATE MEDICINE LICENSING BOARD
NMA-2047-17OtherNM BOARD OF OSTEOPATHIC MEDICINE