Healthcare Provider Details

I. General information

NPI: 1467880302
Provider Name (Legal Business Name): AMY JENSEN CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

IV. Provider business mailing address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

V. Phone/Fax

Practice location:
  • Phone: 904-360-7022
  • Fax: 904-798-4545
Mailing address:
  • Phone: 904-360-7022
  • Fax: 904-798-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA12310
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: