Healthcare Provider Details

I. General information

NPI: 1861533465
Provider Name (Legal Business Name): TRISHA TAGE JENSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 E PAGES LN SUITE A
CENTERVILLE UT
84014-2216
US

IV. Provider business mailing address

125 N STATE ST
SALT LAKE CITY UT
84150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-294-0578
  • Fax: 801-298-2147
Mailing address:
  • Phone: 801-541-4944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6364085-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: