Provider Demographics
NPI:1093042798
Name:JESSEN, G. KAY
Entity Type:Individual
Prefix:
First Name:G.
Middle Name:KAY
Last Name:JESSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:UT
Mailing Address - Zip Code:84086-0232
Mailing Address - Country:US
Mailing Address - Phone:307-677-3394
Mailing Address - Fax:307-789-1902
Practice Address - Street 1:100 BEAR RIVER DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-2804
Practice Address - Country:US
Practice Address - Phone:307-789-0664
Practice Address - Fax:307-789-1902
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator