Provider Demographics
NPI:1790893865
Name:JENSEN, DOUGLAS LYNN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LYNN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MSW, LICSW
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1360 ENERGY PARK DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5276
Mailing Address - Country:US
Mailing Address - Phone:651-646-8985
Mailing Address - Fax:651-646-3959
Practice Address - Street 1:1360 ENERGY PARK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5276
Practice Address - Country:US
Practice Address - Phone:651-646-8985
Practice Address - Fax:651-646-3959
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN113741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01009905OtherPREFERRED ONE
MN2915201-00Medicaid
MN42G10JEOtherBCBS