Basic Information
| Provider Information | |||||||||
| NPI: | 1992255848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | JEREMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 E. 100 S. | ||||||||
| Address2: | |||||||||
| City: | CASTLEDALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4353812432 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2016 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 11450229-6009 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.