Healthcare Provider Details

I. General information

NPI: 1124230115
Provider Name (Legal Business Name): MICHAEL D JENSEN LCSW BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SOUTH MAIN # 25
MANTI UT
84642
US

IV. Provider business mailing address

PO BOX 936
GUNNISON UT
84634-0936
US

V. Phone/Fax

Practice location:
  • Phone: 435-528-7048
  • Fax: 435-528-7048
Mailing address:
  • Phone: 435-528-7048
  • Fax: 435-528-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1140763501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: