Healthcare Provider Details

I. General information

NPI: 1629701941
Provider Name (Legal Business Name): KAYLEE JENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N 3RD ST
WAUSAU WI
54403-4708
US

IV. Provider business mailing address

708 WASHINGTON ST
WAUSAU WI
54403-5667
US

V. Phone/Fax

Practice location:
  • Phone: 715-841-9830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7967-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: