Provider Demographics
NPI:1265435937
Name:JENSEN, GERALD EDWARD JR (MA, LP)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:EDWARD
Last Name:JENSEN
Suffix:JR
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:E
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LP
Mailing Address - Street 1:PO BOX 2633
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2633
Mailing Address - Country:US
Mailing Address - Phone:218-822-3736
Mailing Address - Fax:
Practice Address - Street 1:2155 ANTLER DR SW
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2589
Practice Address - Country:US
Practice Address - Phone:218-822-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4642103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP4642OtherMN PSYCHOLOGY LICENSE