Healthcare Provider Details

I. General information

NPI: 1164235206
Provider Name (Legal Business Name): CARTER DESCH JENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N BOONE ST
OLNEY IL
62450-2109
US

IV. Provider business mailing address

415 DOUGLAS DR
OLNEY IL
62450-3601
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-3226
  • Fax:
Mailing address:
  • Phone: 618-320-0042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: