Basic Information
| Provider Information | |||||||||
| NPI: | 1962142075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | KGH CONSULTATION AND TREATMENT INC | ||||||||
| Address2: | 1161 LAKE COOK ROAD | ||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2242842240 | ||||||||
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| Practice Location | |||||||||
| Address1: | KGH CONSULTATION AND TREATMENT INC., | ||||||||
| Address2: | 3113 WEST BELTLINE HWY | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088196910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2022 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-22-204995 | WI | Y |
No ID Information.