Healthcare Provider Details

I. General information

NPI: 1568946911
Provider Name (Legal Business Name): SHANI LEE JENSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 N MAIN ST STE 250-D
LOGAN UT
84321-3994
US

IV. Provider business mailing address

580 N MAIN ST STE 250-D
LOGAN UT
84321-3994
US

V. Phone/Fax

Practice location:
  • Phone: 435-890-0198
  • Fax:
Mailing address:
  • Phone: 435-890-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number378278-3501
License Number StateUT

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: