Provider Demographics
NPI:1023362035
Name:KELLIE J JENSEN
Entity Type:Organization
Organization Name:KELLIE J JENSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-217-1311
Mailing Address - Street 1:729 FORT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-2316
Mailing Address - Country:US
Mailing Address - Phone:307-217-1311
Mailing Address - Fax:307-684-2182
Practice Address - Street 1:729 FORT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-2316
Practice Address - Country:US
Practice Address - Phone:307-217-1311
Practice Address - Fax:307-684-2182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty