Provider Demographics
NPI:1871695510
Name:JENSON, HAL BROCKBANK (MD, MBA)
Entity type:Individual
Prefix:
First Name:HAL
Middle Name:BROCKBANK
Last Name:JENSON
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 CHESTNUT ST
Mailing Address - Street 2:BAYSTATE MEDICAL CENTER, DIVISION OF ACADEMIC AFFAIRS
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5588
Mailing Address - Fax:413-794-0300
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:BAYSTATE MEDICAL CENTER, DIVISION OF ACADEMIC AFFAIRS
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1001
Practice Address - Country:US
Practice Address - Phone:413-794-5588
Practice Address - Fax:413-794-0300
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226506208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP08277181Medicaid
JE0827718Medicare ID - Type Unspecified
TXP08277181Medicaid