Healthcare Provider Details

I. General information

NPI: 1316600968
Provider Name (Legal Business Name): TYLER J JENSEN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 SW ALASKA ST STE B
SEATTLE WA
98116-4527
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-3399
  • Fax: 206-320-5506
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY61037683
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: