MEDICARE: DR. JENISE JENSEN PHD

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	103G00000X	Clinical Neuropsychologist	6274715-2501	UT
2	103TC2200X	Clinical Child & Adolescent Psychologist	6274715-2501	UT

General Provider Information

NPI Number	:	1366534943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENISE JENSEN PHD

Provider Business Mailing Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 330
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-0195
Fax Number	:	801-355-0199

Provider Business Practice Location Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 330
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-0195
Fax Number	:	801-355-0199

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	06/04/2013

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