Provider Demographics
NPI:1871596585
Name:GERALD E. JENSEN, JR.
Entity type:Organization
Organization Name:GERALD E. JENSEN, JR.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:218-822-3736
Mailing Address - Street 1:PO BOX 2633
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2633
Mailing Address - Country:US
Mailing Address - Phone:218-822-3736
Mailing Address - Fax:218-822-3761
Practice Address - Street 1:6980 FAIRVIEW RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-7836
Practice Address - Country:US
Practice Address - Phone:218-822-3736
Practice Address - Fax:218-822-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4642103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN555519100Medicaid