Provider Demographics
NPI:1225046840
Name:JENSEN, KRISTIN M (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 E 42ND ST
Mailing Address - Street 2:SUITE #315
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5946
Mailing Address - Country:US
Mailing Address - Phone:432-550-0224
Mailing Address - Fax:432-550-3616
Practice Address - Street 1:3800 E 42ND ST
Practice Address - Street 2:SUITE #315
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5946
Practice Address - Country:US
Practice Address - Phone:432-550-0224
Practice Address - Fax:432-550-3616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23779103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L12AMedicare PIN
TXR69869Medicare UPIN