Basic Information
Provider Information | |||||||||
NPI: | 1649201419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENSEN | ||||||||
FirstName: | BRUCE | ||||||||
MiddleName: | LAMONT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENSEN | ||||||||
OtherFirstName: | BRUCE | ||||||||
OtherMiddleName: | LAMONT | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 11059 E. BETHANY DRIVE | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 80014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036172300 | ||||||||
FaxNumber: | 3036172365 | ||||||||
Practice Location | |||||||||
Address1: | 1646 ELMIRA STREET | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 80010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033998020 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 07/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 16467 | CO | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 02752824 | 05 | CO |   | MEDICAID |