Provider Demographics
NPI:1548867427
Name:JENSEN, GRIFFIN CHRISTIAN ROYALE
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:CHRISTIAN ROYALE
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-2602
Mailing Address - Country:US
Mailing Address - Phone:612-220-2385
Mailing Address - Fax:
Practice Address - Street 1:731 BIELENBERG DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:612-445-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician