Provider Demographics
NPI:1083655328
Name:JENSEN, GAYLE LYNNETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:LYNNETTE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 PALM AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6597
Mailing Address - Country:US
Mailing Address - Phone:619-972-5320
Mailing Address - Fax:619-460-4019
Practice Address - Street 1:4323 PALM AVE STE D
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6597
Practice Address - Country:US
Practice Address - Phone:619-972-5320
Practice Address - Fax:619-460-4019
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPY 20223103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL202230OtherBLUE SHIELD OF CALIFORNIA
CA0PL202230OtherTRICARE