Provider Demographics
NPI:1710332549
Name:DOCTOR ELIZABETH JENSEN PSYCHIATRY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DOCTOR ELIZABETH JENSEN PSYCHIATRY PROFESSIONAL CORPORATION
Other - Org Name:JENSEN PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:802-777-8703
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-0666
Mailing Address - Country:US
Mailing Address - Phone:802-777-8703
Mailing Address - Fax:802-654-9155
Practice Address - Street 1:27 RYE CIRCLE
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05483
Practice Address - Country:US
Practice Address - Phone:802-777-8703
Practice Address - Fax:802-654-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.00132022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740440122OtherPROVIDER NPI
VT1025437Medicaid