Provider Demographics
NPI:1336118603
Name:JENSEN, JON NORMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:NORMAN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7840 VINELAND LANE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4655
Mailing Address - Country:US
Mailing Address - Phone:763-236-0287
Mailing Address - Fax:763-420-5531
Practice Address - Street 1:7840 VINEWOOD LANE
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4655
Practice Address - Country:US
Practice Address - Phone:763-236-0287
Practice Address - Fax:763-420-5531
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12343103TC2200X
MNLP5024103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336118603OtherNPI