Provider Demographics
NPI:1811311871
Name:JENSEN, MYRIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W HIGHLAND RD STE 102
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4573
Mailing Address - Country:US
Mailing Address - Phone:810-215-1006
Mailing Address - Fax:
Practice Address - Street 1:210 W HIGHLAND RD STE 102
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4573
Practice Address - Country:US
Practice Address - Phone:810-215-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014043103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist