Provider Demographics
NPI:1205656865
Name:HENSON, KALEB MIKAL
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:MIKAL
Last Name:HENSON
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 1:130 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2631
Mailing Address - Country:US
Mailing Address - Phone:208-944-4679
Mailing Address - Fax:208-944-4679
Practice Address - Street 1:130 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2631
Practice Address - Country:US
Practice Address - Phone:208-944-4679
Practice Address - Fax:208-944-4679
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician