Healthcare Provider Details

I. General information

NPI: 1114412350
Provider Name (Legal Business Name): MINDY JENSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 S YELLOWSTONE HWY
REXBURG ID
83440-4059
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-6735
  • Fax:
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-40962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: