Provider Demographics
NPI:1376206698
Name:JENSEN, JOSHUA D (IS)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:JENSEN
Suffix:
Gender:M
Credentials:IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 CORNELISON AVE APT 2306
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2752
Mailing Address - Country:US
Mailing Address - Phone:775-233-3934
Mailing Address - Fax:
Practice Address - Street 1:720 CORNELISON AVE APT 2306
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2752
Practice Address - Country:US
Practice Address - Phone:775-233-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician