Basic Information
| Provider Information | |||||||||
| NPI: | 1518138049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | LICENSEDPSYCHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 VALPREDA ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607366700 | ||||||||
| FaxNumber: | 7607368740 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 VALPREDA ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607366700 | ||||||||
| FaxNumber: | 7607368740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 11/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 67249902501 | UT | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY26041 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PSY26041 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.