Provider Demographics
NPI:1427304393
Name:JENSEN, STACY (MS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STEELE RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04071-5524
Mailing Address - Country:US
Mailing Address - Phone:207-428-3202
Mailing Address - Fax:
Practice Address - Street 1:12 STEELE RD
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:ME
Practice Address - Zip Code:04071-5524
Practice Address - Country:US
Practice Address - Phone:207-428-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPE832103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist