Provider Demographics
NPI:1962142075
Name:JENSEN, SAMANTHA (RBT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KGH CONSULTATION AND TREATMENT INC
Mailing Address - Street 2:1161 LAKE COOK ROAD
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5649
Mailing Address - Country:US
Mailing Address - Phone:224-284-2240
Mailing Address - Fax:
Practice Address - Street 1:KGH CONSULTATION AND TREATMENT INC.,
Practice Address - Street 2:3113 WEST BELTLINE HWY
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713
Practice Address - Country:US
Practice Address - Phone:608-819-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIRBT-22-204995106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician