Provider Demographics
NPI:1245408400
Name:JENSEN, MARIA G (RN, ICADC)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:G
Last Name:JENSEN
Suffix:
Gender:F
Credentials:RN, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-3231
Mailing Address - Country:US
Mailing Address - Phone:208-878-2600
Mailing Address - Fax:208-878-1336
Practice Address - Street 1:2975 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3231
Practice Address - Country:US
Practice Address - Phone:208-878-2600
Practice Address - Fax:208-878-1336
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-15573101YA0400X
ID10256980101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010028634OtherREGENCE BLUE SHIELD