Basic Information
Provider Information | |||||||||
NPI: | 1023276417 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENSEN | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1220 DEWEY AVE | ||||||||
Address2: |   | ||||||||
City: | WAUWATOSA | ||||||||
State: | WI | ||||||||
PostalCode: | 532132504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4144546779 | ||||||||
FaxNumber: | 4144546450 | ||||||||
Practice Location | |||||||||
Address1: | 8901 W LINCOLN AVE | ||||||||
Address2: |   | ||||||||
City: | WEST ALLIS | ||||||||
State: | WI | ||||||||
PostalCode: | 532272409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4143295657 | ||||||||
FaxNumber: | 4143295637 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3639 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 43593900 | 05 | WI |   | MEDICAID |