Provider Demographics
NPI:1942870423
Name:JENSEN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BRUCE ST APT 44
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2155
Mailing Address - Country:US
Mailing Address - Phone:801-529-6884
Mailing Address - Fax:
Practice Address - Street 1:400 BRUCE ST APT 44
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-2155
Practice Address - Country:US
Practice Address - Phone:801-529-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor