Provider Demographics
NPI:1841961547
Name:JENSSEN, KELLY MARIE (LGPC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:JENSSEN
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 ALLWOOD LN APT 203
Mailing Address - Street 2:
Mailing Address - City:BELCAMP
Mailing Address - State:MD
Mailing Address - Zip Code:21017-2636
Mailing Address - Country:US
Mailing Address - Phone:908-310-4116
Mailing Address - Fax:
Practice Address - Street 1:1402 ALLWOOD LN APT 203
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-2636
Practice Address - Country:US
Practice Address - Phone:908-310-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11856101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health