Provider Demographics
NPI:1730791435
Name:JENSEN, DEREK MICHAEL (IDC)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:MICHAEL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST MEDICAL BATTALION
Mailing Address - Street 2:22 AREA BLDG. 22190
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92058
Mailing Address - Country:US
Mailing Address - Phone:208-625-7120
Mailing Address - Fax:
Practice Address - Street 1:1ST MEDICAL BATTALION
Practice Address - Street 2:22 AREA BLDG. 22190
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:208-625-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman