=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164235206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARTER DESCH JENSEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2025
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 N BOONE ST
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62450-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-392-3226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 DOUGLAS DR
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62450-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-320-0042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------