Basic Information
| Provider Information | |||||||||
| NPI: | 1114597721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENZEL | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 W PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082090288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1130 W PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082090288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2021 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 69581 | ID | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 69581 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.