Provider Demographics
NPI:1548670698
Name:JENSEN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CLAUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:314 5TH ST W
Mailing Address - Street 2:STE. 1
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1204
Mailing Address - Country:US
Mailing Address - Phone:701-228-3613
Mailing Address - Fax:701-228-3600
Practice Address - Street 1:314 5TH ST W
Practice Address - Street 2:STE. 1
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1204
Practice Address - Country:US
Practice Address - Phone:701-228-3613
Practice Address - Fax:701-228-3600
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1627104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker