Individual
JEDEDIAH LARS JENSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
709 SPRING VALLEY RD, BURLINGTON, WI 53105-7614
(262) 971-1900
Mailing address
3301 W FOREST HOME AVE, MILWAUKEE, WI 53215-2843
(414) 389-2233
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
5101018776
MI
207RS0010X
Sports Medicine (Internal Medicine) Physician
Primary
73430
WI
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
5101018776
MI
208000000X
Pediatrics Physician
5101018776
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100100259
—
WI
Enumeration date
06/02/2010
Last updated
12/06/2021
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