Healthcare Provider Details

I. General information

NPI: 1225559354
Provider Name (Legal Business Name): BETTY ANN JENSEN CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HAILEY AVE
PENDLETON OR
97801-3073
US

IV. Provider business mailing address

1101 I AVE
LA GRANDE OR
97850-2043
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-0162
  • Fax: 541-962-0119
Mailing address:
  • Phone: 541-962-0162
  • Fax: 541-962-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12-06-96
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: