Provider Demographics
NPI:1700295888
Name:JENSEN, BRYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 ORCHARD DRIVE APT 8
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1703 DRESDEN RD APT A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4037
Practice Address - Country:US
Practice Address - Phone:801-830-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10235130-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical