Provider Demographics
NPI:1851709513
Name:JACQUIE JENSEN, MSW, LISAC
Entity Type:Organization
Organization Name:JACQUIE JENSEN, MSW, LISAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUIE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:480-221-4875
Mailing Address - Street 1:2319 N 51ST PL
Mailing Address - Street 2:NUMBER 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-2519
Mailing Address - Country:US
Mailing Address - Phone:480-221-4875
Mailing Address - Fax:
Practice Address - Street 1:2319 N 51ST PL
Practice Address - Street 2:NUMBER 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2519
Practice Address - Country:US
Practice Address - Phone:480-221-4875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11489251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health