Healthcare Provider Details

I. General information

NPI: 1366534943
Provider Name (Legal Business Name): JENISE JENSEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S 1000 E SUITE 330
SALT LAKE CITY UT
84102-1428
US

IV. Provider business mailing address

160 S 1000 E SUITE 330
SALT LAKE CITY UT
84102-1428
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-0195
  • Fax: 801-355-0199
Mailing address:
  • Phone: 801-355-0195
  • Fax: 801-355-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6274715-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6274715-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: