Healthcare Provider Details

I. General information

NPI: 1265435937
Provider Name (Legal Business Name): GERALD EDWARD JENSEN JR. MA, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JERRY E JENSEN MA, LP

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 ANTLER DR SW
BRAINERD MN
56401-2589
US

IV. Provider business mailing address

PO BOX 2633
BAXTER MN
56425-2633
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4642
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: