Healthcare Provider Details

I. General information

NPI: 1063327930
Provider Name (Legal Business Name): JENSEN VAN DUYSE LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4232 DAHLBERG DR
GOLDEN VALLEY MN
55422-4805
US

IV. Provider business mailing address

4232 DAHLBERG DR
GOLDEN VALLEY MN
55422-4805
US

V. Phone/Fax

Practice location:
  • Phone: 763-465-5089
  • Fax: 612-874-9820
Mailing address:
  • Phone: 763-465-5089
  • Fax: 612-874-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307399
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: