Basic Information
Provider Information
NPI: 1003156118
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JENSEN
FirstName: STEVEN
MiddleName: ALEC
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5965 S 900 E
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 841211720
CountryCode: US
TelephoneNumber: 8012637100
FaxNumber:  
Practice Location
Address1: 5965 S 900 E
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 841211720
CountryCode: US
TelephoneNumber: 8012637100
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/26/2013
LastUpdateDate: 02/26/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  Y Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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