Provider Demographics
NPI:1871060392
Name:JENSEN-WISETSARAKOOL, AMY (MS,CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JENSEN-WISETSARAKOOL
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 INDIAN PAINTBRUSH
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-9301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5242 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032
Practice Address - Country:US
Practice Address - Phone:972-772-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist