Provider Demographics
NPI:1306002803
Name:PHYLLIS K. JENSEN, PSY.D.,L.L.C.
Entity Type:Organization
Organization Name:PHYLLIS K. JENSEN, PSY.D.,L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:941-485-0854
Mailing Address - Street 1:871 VENETIA BAY BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-8047
Mailing Address - Country:US
Mailing Address - Phone:941-485-0854
Mailing Address - Fax:941-480-9013
Practice Address - Street 1:871 VENETIA BAY BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-8047
Practice Address - Country:US
Practice Address - Phone:941-485-0854
Practice Address - Fax:941-480-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6912302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74181Medicare PIN