Provider Demographics
NPI:1922100882
Name:JENSEN, NATHAN CHARLES (LAC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:CHARLES
Last Name:JENSEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6430
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-6430
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-872-2441
Practice Address - Street 1:12 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1822
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-872-2441
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0509061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health