Provider Demographics
NPI:1548292436
Name:JENSEN, THOMAS R (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7209
Mailing Address - Country:US
Mailing Address - Phone:414-325-4940
Mailing Address - Fax:
Practice Address - Street 1:10101 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7209
Practice Address - Country:US
Practice Address - Phone:414-325-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00449580OtherRR MEDICARE
WI30931600Medicaid
WI73500-0173Medicare ID - Type Unspecified
WI30931600Medicaid
WI01994-0255Medicare PIN
WIB53859Medicare UPIN
WIP00449580OtherRR MEDICARE