Provider Demographics
NPI:1205257193
Name:JENSEN, MARY PHYLLIS (CCC-SLP, MS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PHYLLIS
Last Name:JENSEN
Suffix:
Gender:F
Credentials:CCC-SLP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4690 NE NORTH TOLO RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1429
Mailing Address - Country:US
Mailing Address - Phone:206-913-3236
Mailing Address - Fax:
Practice Address - Street 1:4690 NE NORTH TOLO RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1429
Practice Address - Country:US
Practice Address - Phone:206-913-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist