Provider Demographics
NPI:1114394764
Name:JENSEN, LESLIE
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 E SHADOW RIDGE DR APT 11J
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4255
Mailing Address - Country:US
Mailing Address - Phone:801-792-4621
Mailing Address - Fax:
Practice Address - Street 1:1525 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5638
Practice Address - Country:US
Practice Address - Phone:801-621-6510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health