Provider Demographics
NPI:1386739837
Name:JENSEN, KEVIN NEAL (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:NEAL
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 1:3750 E COUNTRY FIELD CIR STE B
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6659
Mailing Address - Country:US
Mailing Address - Phone:907-373-1410
Mailing Address - Fax:907-373-1411
Practice Address - Street 1:3750 E COUNTRY FIELD CIR STE B
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6659
Practice Address - Country:US
Practice Address - Phone:907-373-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107880207YX0905X
OH31.008805208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1386739837OtherNPI
AK1695669Medicaid