Provider Demographics
NPI:1144617572
Name:JENSEN, MELISSA RUBY
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RUBY
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 1:250 E 22ND ST
Mailing Address - Street 2:APT 103
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1533
Mailing Address - Country:US
Mailing Address - Phone:801-510-8825
Mailing Address - Fax:
Practice Address - Street 1:237 26TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3105
Practice Address - Country:US
Practice Address - Phone:801-399-7832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT10981190-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid