Healthcare Provider Details

I. General information

NPI: 1255339297
Provider Name (Legal Business Name): DR. KACI B. JENSEN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W LEO DR
BOISE ID
83709-8249
US

IV. Provider business mailing address

9755 W LEO DR
BOISE ID
83709-8249
US

V. Phone/Fax

Practice location:
  • Phone: 208-791-4926
  • Fax:
Mailing address:
  • Phone: 208-791-4926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2000159748
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4034
License Number StateID

VIII. Authorized Official

Name: DR. KACI B. JENSEN
Title or Position: OWNER
Credential: DDS
Phone: 208-791-4926