Provider Demographics
NPI:1902684848
Name:JENSEN, MICHAEL RAYMOND (RBT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:JENSEN
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 FORTRESS RD
Mailing Address - Street 2:
Mailing Address - City:EHRHARDT
Mailing Address - State:SC
Mailing Address - Zip Code:29081-9027
Mailing Address - Country:US
Mailing Address - Phone:863-279-5419
Mailing Address - Fax:
Practice Address - Street 1:328 GLEN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4653
Practice Address - Country:US
Practice Address - Phone:843-834-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-23-298463106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician