Provider Demographics
NPI:1235434010
Name:CARLSEN, JENNIFER LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:CARLSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 S TOPAZ WAY STE 106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4401
Mailing Address - Country:US
Mailing Address - Phone:208-672-4640
Mailing Address - Fax:208-957-6300
Practice Address - Street 1:1859 S TOPAZ WAY STE 106
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4401
Practice Address - Country:US
Practice Address - Phone:208-672-4640
Practice Address - Fax:208-957-6300
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant