Provider Demographics
NPI:1104225234
Name:JENSEN, JOSHUA T
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:T
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 N. BUTLIN DR.
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2722
Mailing Address - Country:US
Mailing Address - Phone:608-346-8994
Mailing Address - Fax:
Practice Address - Street 1:S1597 HANSON RD
Practice Address - Street 2:
Practice Address - City:WESTBY
Practice Address - State:WI
Practice Address - Zip Code:54667-8396
Practice Address - Country:US
Practice Address - Phone:608-346-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2215226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI101YM0800XMedicaid