Provider Demographics
NPI:1366481269
Name:JENSEN, VICKI ANN (CCC/SLP-L)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:ANN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:CCC/SLP-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 N HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-3320
Mailing Address - Country:US
Mailing Address - Phone:928-978-5101
Mailing Address - Fax:
Practice Address - Street 1:2451 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2471
Practice Address - Country:US
Practice Address - Phone:480-474-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146004089235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist