MEDICARE: VICKI ANN JENSEN CCC/SLP-L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146004089	IL

General Provider Information

NPI Number	:	1366481269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI ANN JENSEN CCC/SLP-L

Provider Business Mailing Address
First Line	:	1108 N HILLCREST DR
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-3320
Country	:	US
Telephone Number	:	928-978-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 E BASELINE RD
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-2471
Country	:	US
Telephone Number	:	480-474-4173
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	04/18/2018

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Directions to “ VICKI ANN JENSEN CCC/SLP-L” Practice Location

Language	Start Address	Practice Location

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