Provider Demographics
NPI:1184602351
Name:JENSEN, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6695
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:1248 E 90 N STE 103
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2954
Practice Address - Country:US
Practice Address - Phone:801-852-9560
Practice Address - Fax:801-852-9559
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47680208200000X, 208600000X
UT7903019-1205208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34841700Medicaid
IAENROLLEDMedicaid
MN425475900Medicaid
MNP00746335OtherRAILROAD MEDICARE
MN020002155Medicare PIN
IAENROLLEDMedicaid