Provider Demographics
NPI:1699803148
Name:HENSELEN, JAY C (CRNA)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:C
Last Name:HENSELEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 N 100W
Mailing Address - Street 2:PO BOX 1670
Mailing Address - City:BEAVER
Mailing Address - State:UT
Mailing Address - Zip Code:84713-1670
Mailing Address - Country:US
Mailing Address - Phone:435-438-7100
Mailing Address - Fax:
Practice Address - Street 1:1109 N 100W
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:UT
Practice Address - Zip Code:84713-1670
Practice Address - Country:US
Practice Address - Phone:435-438-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered