Provider Demographics
NPI:1760978829
Name:JENSEN, MELISSA A (MA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1627
Mailing Address - Country:US
Mailing Address - Phone:618-345-9644
Mailing Address - Fax:
Practice Address - Street 1:907 N BLUFF RD STE 9
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-5816
Practice Address - Country:US
Practice Address - Phone:618-345-9644
Practice Address - Fax:618-345-6577
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health