Provider Demographics
NPI:1588318828
Name:JENSEN, HALLIE NICOLE
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:NICOLE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 S MERIDIAN RD STE 140
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8051
Mailing Address - Country:US
Mailing Address - Phone:208-901-4888
Mailing Address - Fax:
Practice Address - Street 1:2985 S MERIDIAN RD STE 140
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8051
Practice Address - Country:US
Practice Address - Phone:208-901-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
801287622OtherSELECT HEALTH