Provider Demographics
NPI:1346880655
Name:JENSEN, COLE SYMON
Entity Type:Individual
Prefix:MR
First Name:COLE
Middle Name:SYMON
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 LATHROP ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7426
Mailing Address - Country:US
Mailing Address - Phone:907-474-0890
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7426
Practice Address - Country:US
Practice Address - Phone:907-474-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK010354Medicaid