Healthcare Provider Details

I. General information

NPI: 1124712443
Provider Name (Legal Business Name): CAITLIN JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E SD HIGHWAY 34
PIERRE SD
57501-6804
US

IV. Provider business mailing address

28243 409TH AVE
PARKSTON SD
57366-6217
US

V. Phone/Fax

Practice location:
  • Phone: 605-773-7475
  • Fax:
Mailing address:
  • Phone: 712-592-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberCP002833
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: