Provider Demographics
NPI:1679624936
Name:JENSEN, LAURENCE G (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:G
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HEATHER CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1057
Mailing Address - Country:US
Mailing Address - Phone:719-542-5349
Mailing Address - Fax:719-564-1659
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE A535
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-0450
Practice Address - Fax:719-564-1659
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01209915Medicaid
COC197348Medicare ID - Type Unspecified
CO110163665Medicare PIN
CO01209915Medicaid