Provider Demographics
NPI:1366534943
Name:JENSEN, JENISE (PHD)
Entity type:Individual
Prefix:DR
First Name:JENISE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S 1000 E
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1428
Mailing Address - Country:US
Mailing Address - Phone:801-355-0195
Mailing Address - Fax:801-355-0199
Practice Address - Street 1:160 S 1000 E
Practice Address - Street 2:SUITE 330
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1428
Practice Address - Country:US
Practice Address - Phone:801-355-0195
Practice Address - Fax:801-355-0199
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6274715-2501103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent