Provider Demographics
NPI:1104531722
Name:GORMAN, JENSEN
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 TORREY LN APT B
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2539
Mailing Address - Country:US
Mailing Address - Phone:636-278-0903
Mailing Address - Fax:
Practice Address - Street 1:1319 CALLE AVANZADO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6351
Practice Address - Country:US
Practice Address - Phone:949-272-6146
Practice Address - Fax:888-847-8864
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician