Provider Demographics
NPI:1902351075
Name:JENSEN, RACHAEL VICTORIA (BSW, QIDP)
Entity Type:Individual
Prefix:MISS
First Name:RACHAEL
Middle Name:VICTORIA
Last Name:JENSEN
Suffix:
Gender:F
Credentials:BSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 LOUSMA DR SE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2251
Mailing Address - Country:US
Mailing Address - Phone:616-241-6258
Mailing Address - Fax:616-241-6470
Practice Address - Street 1:3353 LOUSMA DR SE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548
Practice Address - Country:US
Practice Address - Phone:616-241-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382882853Medicaid