MEDICARE: DR. BRYAN JENSEN PHD

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
1	103TC0700X	Clinical Psychologist	10235130-2501	UT

General Provider Information

NPI Number	:	1700295888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN JENSEN PHD

Provider Business Mailing Address
First Line	:	629 ORCHARD DRIVE APT 8
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 DRESDEN RD APT A
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-4037
Country	:	US
Telephone Number	:	801-830-5593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2014
Last Update Date	:	07/05/2017

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