Provider Demographics
NPI:1740705995
Name:JENSEN, MARIAM A (LCMFT)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:A
Last Name:JENSEN
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:A
Other - Last Name:MIKHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:2420 N WOODLAWN BLVD
Mailing Address - Street 2:BLDG 100 STE K
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-3960
Mailing Address - Country:US
Mailing Address - Phone:316-779-4337
Mailing Address - Fax:316-776-4509
Practice Address - Street 1:2420 N WOODLAWN BLVD
Practice Address - Street 2:BLDG 100 STE K
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-3960
Practice Address - Country:US
Practice Address - Phone:316-779-4337
Practice Address - Fax:316-776-4509
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2997106H00000X
KS2880106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201165860BMedicaid