Provider Demographics
NPI:1518248111
Name:JENSEN, ANNETTE MARIE (QMHA)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:8485 ANDERSON RD. SE
Mailing Address - City:SUBLIMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97385-0289
Mailing Address - Country:US
Mailing Address - Phone:503-769-4244
Mailing Address - Fax:
Practice Address - Street 1:2421 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1220
Practice Address - Country:US
Practice Address - Phone:503-576-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator