Provider Demographics
NPI:1124620117
Name:JENSEN, BETHANY KRISTINE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:KRISTINE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:K
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3455 SW US VETERANS HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3076
Mailing Address - Country:US
Mailing Address - Phone:503-983-6089
Mailing Address - Fax:
Practice Address - Street 1:3180 CENTER ST NE STE 2100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4532
Practice Address - Country:US
Practice Address - Phone:503-588-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202010385NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health