Healthcare Provider Details

I. General information

NPI: 1184128175
Provider Name (Legal Business Name): ZACHARIAH JON JENSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 05/28/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N CURTIS RD
BOISE ID
83706-1445
US

IV. Provider business mailing address

PO BOX 8111
BOISE ID
83707-2111
US

V. Phone/Fax

Practice location:
  • Phone: 208-605-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number0102205792
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberCL0461
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number010906
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number12884
License Number StateSD
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberO-1779
License Number StateID
# 6
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number12884
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: