Provider Demographics
NPI:1538826029
Name:JENSEN, MARIAH KALA (MSW)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:KALA
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11011 W NORTH AVE APT 463
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2275
Mailing Address - Country:US
Mailing Address - Phone:262-337-1609
Mailing Address - Fax:
Practice Address - Street 1:3505 N 124TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222
Practice Address - Country:US
Practice Address - Phone:414-431-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132497-121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health