Provider Demographics
NPI:1770097131
Name:JENSEN, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
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 198
Mailing Address - Street 2:
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0198
Mailing Address - Country:US
Mailing Address - Phone:309-867-2202
Mailing Address - Fax:
Practice Address - Street 1:1204 HIGHWAY 164E
Practice Address - Street 2:
Practice Address - City:OQUAWKA
Practice Address - State:IL
Practice Address - Zip Code:61469
Practice Address - Country:US
Practice Address - Phone:309-867-2202
Practice Address - Fax:309-867-2789
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490091021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical