Healthcare Provider Details

I. General information

NPI: 1487125969
Provider Name (Legal Business Name): HAILEY ANNE JENSEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HAILEY ANNE CLARK FNP-C

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 POTOMAC WAY
IDAHO FALLS ID
83404-4970
US

IV. Provider business mailing address

3450 POTOMAC WAY
IDAHO FALLS ID
83404-4970
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2900
  • Fax: 208-557-2959
Mailing address:
  • Phone: 208-557-2900
  • Fax: 208-557-2959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number60009
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: