Provider Demographics
NPI:1477721637
Name:JENSEN, WILLIAM F (MBA, ICADC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:F
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MBA, ICADC
Other - Prefix:MR
Other - First Name:BILL
Other - Middle Name:F
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MBA, ICADC
Mailing Address - Street 1:2975 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-3231
Mailing Address - Country:US
Mailing Address - Phone:208-878-2600
Mailing Address - Fax:208-878-1336
Practice Address - Street 1:2975 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3231
Practice Address - Country:US
Practice Address - Phone:208-878-2600
Practice Address - Fax:208-878-1336
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1006393101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010028636OtherREGENCE BLUE SHIELD