Provider Demographics
NPI:1750619110
Name:JENSEN, RUSSELL VANCE (MA, EDM, LMFT)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:VANCE
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MA, EDM, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-0546
Mailing Address - Country:US
Mailing Address - Phone:559-240-5742
Mailing Address - Fax:
Practice Address - Street 1:2080 N WINERY AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-4817
Practice Address - Country:US
Practice Address - Phone:559-640-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 88760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist