Basic Information
| Provider Information | |||||||||
| NPI: | 1316060890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1646 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833017817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087347362 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1646 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833017817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087347362 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 08/14/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | O-0439 | ID | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.