Provider Demographics
NPI:1841329356
Name:JENSEN, MIRIAM A
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:A
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 1:5931 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-9780
Mailing Address - Country:US
Mailing Address - Phone:907-796-8654
Mailing Address - Fax:907-586-5605
Practice Address - Street 1:3250 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-9501
Practice Address - Country:US
Practice Address - Phone:907-796-8654
Practice Address - Fax:907-586-5605
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1841329356Medicaid