Provider Demographics
NPI:1477113041
Name:JENSEN, CORTNEY NICOLE (CDPT)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:NICOLE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 KRESKY AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-8982
Mailing Address - Country:US
Mailing Address - Phone:360-388-4048
Mailing Address - Fax:360-669-0676
Practice Address - Street 1:1611 KRESKY AVE STE 114
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8982
Practice Address - Country:US
Practice Address - Phone:360-388-4048
Practice Address - Fax:360-669-0676
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60853234101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)