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NPI Code Detail

MEDICARE: KELLY JENSEN ICADC

MEDICARE: KELLY JENSEN ICADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor827461GU

General Provider Information

NPI Number : 1386241511
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY JENSEN ICADC
Provider Business Mailing Address
First Line : 255 DELAWARE AVE STE 3000
Second Line :
City : BUFFALO
State : NY
Zip : 14202-2016
Country : US
Telephone Number : 716-842-0440
Fax Number :
Provider Business Practice Location Address
First Line : 255 DELAWARE AVE STE 3000
Second Line :
City : BUFFALO
State : NY
Zip : 14202-2016
Country : US
Telephone Number : 716-842-0440
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/01/2020
Last Update Date : 10/01/2020

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