Basic Information
| Provider Information | |||||||||
| NPI: | 1255390761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
| FaxNumber: | 2065203186 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD00032728 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD00032728 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0200JE | 01 | REGENCE | OTHER | 106607 | 01 | WA | H & I | OTHER | 7098660 | 01 | AETNA | OTHER | 300066435 | 01 | WA | RAILROAD | OTHER | JE4602 | 01 | REGENCE | OTHER | 1255390761 | 05 | WA | MEDICAID | 201454644 | 01 | TAX ID | OTHER | 022278001 | 01 | GROUP HEALTH | OTHER | 7822109 | 05 | WA | MEDICAID | 55900 | 01 | WA | H & I | OTHER | 8188278 | 05 | WA | MEDICAID | 910849248 | 01 | TAX ID | OTHER | WE4663 | 01 | REGENCE | OTHER |