MEDICARE: DENISE JENSEN MSW, LCSW

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	104100000X	Social Worker	33004892A	IN
2	1041C0700X	Clinical Social Worker
3	1041C0700X	Clinical Social Worker	34008473A	IN

General Provider Information

NPI Number	:	1669757225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE JENSEN MSW, LCSW

Provider Business Mailing Address
First Line	:	12306 GOLDENEYES CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9160
Country	:	US
Telephone Number	:	574-304-3661
Fax Number	:

Provider Business Practice Location Address
First Line	:	12306 GOLDENEYES CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9160
Country	:	US
Telephone Number	:	574-304-3661
Fax Number	:

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

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	11/07/2019

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