MEDICARE: MR. JAMES WILLIAM 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	R016718-1	NY
2	1041C0700X	Clinical Social Worker	R018716-1	NY

General Provider Information

NPI Number	:	1902120801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES WILLIAM JENSEN LCSW

Provider Business Mailing Address
First Line	:	163 W 125TH ST
Second Line	:	12TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10027-4436
Country	:	US
Telephone Number	:	212-961-8711
Fax Number	:	212-866-2760

Provider Business Practice Location Address
First Line	:	163 W 125TH ST
Second Line	:	12TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10027-4436
Country	:	US
Telephone Number	:	212-961-8711
Fax Number	:	212-866-2760

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

Provider Enumeration Date	:	03/22/2010
Last Update Date	:	03/22/2010

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