Basic Information
| Provider Information | |||||||||
| NPI: | 1790893865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MSW, LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 ENERGY PARK DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516468985 | ||||||||
| FaxNumber: | 6516463959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 ENERGY PARK DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516468985 | ||||||||
| FaxNumber: | 6516463959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11374 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01009905 | 01 | MN | PREFERRED ONE | OTHER | 2915201-00 | 05 | MN | MEDICAID | 42G10JE | 01 | MN | BCBS | OTHER |