=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023362035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLIE J JENSEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2012
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 FORT ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82834-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-217-1311
-----------------------------------------------------
Fax | 307-684-2182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 FORT ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82834-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-217-1311
-----------------------------------------------------
Fax | 307-684-2182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | KELLIE J JENSEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 307-217-1311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 661
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------