=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770937880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTENSEN FAMILY THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2016
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 S MAIN ST
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-757-3440
-----------------------------------------------------
Fax | 919-562-5696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1529 MAIN DIVIDE DR
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-6194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-435-1683
-----------------------------------------------------
Fax | 919-562-5696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JEFFREY JAY CHRISTENSEN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 919-757-3440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1138
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------