Provider Demographics
NPI:1629171608
Name:JESSEN, KRISTEN B (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:B
Last Name:JESSEN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 N FIREWEED ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7570
Mailing Address - Country:US
Mailing Address - Phone:907-714-4090
Mailing Address - Fax:907-262-2476
Practice Address - Street 1:289 N FIREWEED ST STE D
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7570
Practice Address - Country:US
Practice Address - Phone:907-714-4090
Practice Address - Fax:907-262-2476
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDLT 103582084N0400X
MO20050052912084N0400X
AZ355432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207331802Medicaid
MO207331802Medicaid