MEDICARE: CHERLYN JENSEN

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1952641763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERLYN JENSEN

Provider Business Mailing Address
First Line	:	91-1091 WAIKAPOO ST # 206
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-6494
Country	:	US
Telephone Number	:	808-478-1981
Fax Number	:

Provider Business Practice Location Address
First Line	:	91-1091 WAIKAPOO ST
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-6494
Country	:	US
Telephone Number	:	808-478-1981
Fax Number	:

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

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	04/18/2022

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