Provider Demographics
NPI:1518949015
Name:JENSEN, HEIDI MARIE (LP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:MARIE
Other - Last Name:NEISWENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0820103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
004586Medicare ID - Type Unspecified