MEDICARE: SUSAN MCQUIRK JENSEN M.A.,CCC

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	7107	CA

General Provider Information

NPI Number	:	1700198363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MCQUIRK JENSEN M.A.,CCC

Provider Business Mailing Address
First Line	:	758 E PORTALS AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-6221
Country	:	US
Telephone Number	:	559-289-3443
Fax Number	:

Provider Business Practice Location Address
First Line	:	758 E PORTALS AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-6221
Country	:	US
Telephone Number	:	559-289-3443
Fax Number	:

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

Provider Enumeration Date	:	07/11/2010
Last Update Date	:	07/11/2010

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