Healthcare Provider Details

I. General information

NPI: 1154099588
Provider Name (Legal Business Name): WANDA ETHEL JENSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 03/19/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 3RD AVE
LIMA MT
59739
US

IV. Provider business mailing address

PO BOX 13
LIMA MT
59739-0013
US

V. Phone/Fax

Practice location:
  • Phone: 406-660-0904
  • Fax:
Mailing address:
  • Phone: 406-660-0904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62696
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number37100
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: