Healthcare Provider Details

I. General information

NPI: 1114597721
Provider Name (Legal Business Name): JONATHAN V HENZEL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

958 S LOCHSA ST STE 225
POST FALLS ID
83854-8357
US

IV. Provider business mailing address

958 S LOCHSA ST STE 225
POST FALLS ID
83854-8357
US

V. Phone/Fax

Practice location:
  • Phone: 208-640-2564
  • Fax: 208-908-6338
Mailing address:
  • Phone: 208-640-2564
  • Fax: 208-908-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number69581
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number69581
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: