Healthcare Provider Details

I. General information

NPI: 1962318659
Provider Name (Legal Business Name): NATHAN JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 GIBSON DR APT 2213
ROSEVILLE CA
95678-5413
US

IV. Provider business mailing address

301 GIBSON DR APT 2213
ROSEVILLE CA
95678-5413
US

V. Phone/Fax

Practice location:
  • Phone: 920-660-8532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number900264
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: