Healthcare Provider Details

I. General information

NPI: 1093626152
Provider Name (Legal Business Name): JENSEN B DOMINGO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENSEN B WILGUS

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N BELCREST AVE STE A
SPRINGFIELD MO
65802-6287
US

IV. Provider business mailing address

PO BOX 844715
KANSAS CITY MO
64184-4715
US

V. Phone/Fax

Practice location:
  • Phone: 417-413-4676
  • Fax: 417-763-3308
Mailing address:
  • Phone: 417-761-5214
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2026037867
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: