Provider Demographics
NPI:1295008167
Name:JENSEN, CARLY
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:
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 1:174 HAINES AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1602
Mailing Address - Country:US
Mailing Address - Phone:815-603-8414
Mailing Address - Fax:
Practice Address - Street 1:174 HAINES AVENUE
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1602
Practice Address - Country:US
Practice Address - Phone:815-603-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2381813222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist