Provider Demographics
NPI:1124230115
Name:JENSEN, MICHAEL D (LCSW BCD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:JENSEN
Suffix:
Gender:M
Credentials:LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0936
Mailing Address - Country:US
Mailing Address - Phone:435-528-7048
Mailing Address - Fax:435-528-7048
Practice Address - Street 1:50 SOUTH MAIN
Practice Address - Street 2:# 25
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642
Practice Address - Country:US
Practice Address - Phone:435-528-7048
Practice Address - Fax:435-528-7048
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11407635011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000077045Medicare ID - Type Unspecified