MEDICARE: JENNIFER MAE JENSEN CCC-SLP

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	7350	MN

General Provider Information

NPI Number	:	1386613412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MAE JENSEN CCC-SLP

Provider Business Mailing Address
First Line	:	6776 LAKE DR
Second Line	:	220
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1191
Country	:	US
Telephone Number	:	651-784-7007
Fax Number	:	651-784-7992

Provider Business Practice Location Address
First Line	:	6776 LAKE DR
Second Line	:	220
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1191
Country	:	US
Telephone Number	:	651-784-7007
Fax Number	:	651-784-7992

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/21/2022

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