Provider Demographics
NPI:1184157679
Name:JENSEN, LAURA MARIE (EDS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:18266 JAMAICA PATH
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9616
Mailing Address - Country:US
Mailing Address - Phone:507-213-6844
Mailing Address - Fax:
Practice Address - Street 1:18266 JAMAICA PATH
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9616
Practice Address - Country:US
Practice Address - Phone:507-213-6844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN429233103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool