Healthcare Provider Details

I. General information

NPI: 1649134107
Provider Name (Legal Business Name): LELAND ROYAL JENSEN ADC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2532 N FERRY ST
ANOKA MN
55303-1653
US

IV. Provider business mailing address

2532 N FERRY ST
ANOKA MN
55303-1653
US

V. Phone/Fax

Practice location:
  • Phone: 763-452-7033
  • Fax: 763-427-6084
Mailing address:
  • Phone: 763-452-7033
  • Fax: 612-823-4913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3074
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: