Provider Demographics
NPI:1154099588
Name:JENSEN, WANDA ETHEL (SWLC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:ETHEL
Last Name:JENSEN
Suffix:
Gender:F
Credentials:SWLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 MT HIGHWAY 91 N TRLR 15
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-8329
Mailing Address - Country:US
Mailing Address - Phone:406-660-0904
Mailing Address - Fax:
Practice Address - Street 1:3525 MT HIGHWAY 91 N TRLR 15
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-8329
Practice Address - Country:US
Practice Address - Phone:406-660-0904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT371001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical