Provider Demographics
NPI:1841643087
Name:JENSEN, BYRON KENT
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:KENT
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-1629
Mailing Address - Country:US
Mailing Address - Phone:435-279-4980
Mailing Address - Fax:435-921-0801
Practice Address - Street 1:137 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-1629
Practice Address - Country:US
Practice Address - Phone:435-279-4980
Practice Address - Fax:435-921-0801
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9-723180-0251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9-723180-0Medicaid