Provider Demographics
NPI:1720278880
Name:JENSEN, AMELIA (LICSW)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 W SYLVESTER ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2958
Mailing Address - Country:US
Mailing Address - Phone:509-964-4265
Mailing Address - Fax:509-964-4265
Practice Address - Street 1:4021 W SYLVESTER ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2958
Practice Address - Country:US
Practice Address - Phone:509-964-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00009625104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1125996Medicaid