Provider Demographics
NPI:1851309421
Name:HENSOLD, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HENSOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 HIGHLAND BLVD STE 3130
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:931 HIGHLAND BLVD STE 3130
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6914
Practice Address - Country:US
Practice Address - Phone:406-585-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10576207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0140624Medicaid
P00225963OtherMEDICARE RAILROAD
MT97535OtherBLUE CROSS OF MT
000084620Medicare PIN
MT97535OtherBLUE CROSS OF MT
000084620Medicare ID - Type Unspecified