Provider Demographics
NPI:1982837712
Name:JENSEN, KELLIE JO (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 FORT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-2316
Mailing Address - Country:US
Mailing Address - Phone:307-217-1311
Mailing Address - Fax:307-684-2182
Practice Address - Street 1:729 FORT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-2316
Practice Address - Country:US
Practice Address - Phone:307-217-1311
Practice Address - Fax:307-684-2182
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-6611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical