Healthcare Provider Details

I. General information

NPI: 1891367207
Provider Name (Legal Business Name): JESSICA JENSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S WASATCH BLVD STE 360
SALT LAKE CITY UT
84124-4203
US

IV. Provider business mailing address

4505 S WASATCH BLVD STE 360
SALT LAKE CITY UT
84124-4203
US

V. Phone/Fax

Practice location:
  • Phone: 801-792-9157
  • Fax:
Mailing address:
  • Phone: 801-792-9157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11591626-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: