Healthcare Provider Details

I. General information

NPI: 1316543515
Provider Name (Legal Business Name): TIFFANY MARIE JENSEN LADC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 6TH ST SE
WILLMAR MN
56201-4675
US

IV. Provider business mailing address

PO BOX 787
WILLMAR MN
56201-0787
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-4613
  • Fax: 855-625-7406
Mailing address:
  • Phone: 320-235-4613
  • Fax: 855-625-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC02657
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: