MEDICARE: SUMRE MICHELLE JENSEN 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	1041C0700X	Clinical Social Worker	104379	TX

General Provider Information

NPI Number	:	1760823926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMRE MICHELLE JENSEN LCSW

Provider Business Mailing Address
First Line	:	1631 E 2ND ST STE C
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78702-4491
Country	:	US
Telephone Number	:	512-804-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	1631 E 2ND ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78702-4490
Country	:	US
Telephone Number	:	501-804-3627
Fax Number	:

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

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	05/30/2023

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