Provider Demographics
NPI:1225024870
Name:CHRISTENSEN, JERRY RAY (LISW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:RAY
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1082
Mailing Address - Country:US
Mailing Address - Phone:319-354-6479
Mailing Address - Fax:319-354-6291
Practice Address - Street 1:200 HAWKINS DRIVE
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1082
Practice Address - Country:US
Practice Address - Phone:319-354-6479
Practice Address - Fax:319-354-6291
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33721OtherWELLMARK BCBS
IA33721OtherWELLMARK BCBS
P06946Medicare UPIN