Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 4294 | KS |
NPI | 1285731224 |
---|---|
Provider Name | Dr. Jerald Lee Jensen |
First Address | Long Beach, CA 90822-5201 |
Second Address | Long Beach, CA 90822-5201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 16/06/2009 |