Provider Demographics
NPI:1902351075
Name:JENSEN, RACHAEL VICTORIA (BSW, QIDP)
Entity type:Individual
Prefix:MISS
First Name:RACHAEL
Middle Name:VICTORIA
Last Name:JENSEN
Suffix:
Gender:F
Credentials:BSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35425 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-9800
Mailing Address - Country:US
Mailing Address - Phone:616-550-0604
Mailing Address - Fax:
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-9800
Practice Address - Country:US
Practice Address - Phone:616-550-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382882853Medicaid