Provider Demographics
NPI:1972514214
Name:DR. EDWIN A. JENSEN, D.O., P.A.
Entity type:Organization
Organization Name:DR. EDWIN A. JENSEN, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:ARNT
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-963-2187
Mailing Address - Street 1:602 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1222
Mailing Address - Country:US
Mailing Address - Phone:856-963-2187
Mailing Address - Fax:856-225-1913
Practice Address - Street 1:602 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1222
Practice Address - Country:US
Practice Address - Phone:856-963-2187
Practice Address - Fax:856-225-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02501900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2787008Medicaid
NJ0106612001OtherAMERIHEALTH
NJ32866OtherAMERIGROUP
NJ01000075601OtherAMERICHOICE
NJ32866OtherAMERIGROUP
NJ01000075601OtherAMERICHOICE