Provider Demographics
NPI:1700096724
Name:JENSEN, GREGORY VERNON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:VERNON
Last Name:JENSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:512-257-1763
Practice Address - Street 1:205 E UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-6814
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:512-257-1763
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX539411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215422101Medicaid
TXTXB107498Medicare PIN