Healthcare Provider Details

I. General information

NPI: 1871596585
Provider Name (Legal Business Name): GERALD E. JENSEN, JR.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6980 FAIRVIEW RD SUITE 110
BAXTER MN
56425-7836
US

IV. Provider business mailing address

PO BOX 2633
BAXTER MN
56425-2633
US

V. Phone/Fax

Practice location:
  • Phone: 218-822-3736
  • Fax: 218-822-3761
Mailing address:
  • Phone: 218-822-3736
  • Fax: 218-822-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP 4642
License Number StateMN

VIII. Authorized Official

Name: JERRY E. JENSEN
Title or Position: DIRECTOR
Credential: MA, LP
Phone: 218-822-3736