Provider Demographics
NPI:1487899365
Name:MENTZER, JACLYN GOLUS (PA)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:GOLUS
Last Name:MENTZER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 E. PARKCENTER BLVD. GEM STATE DERMATOLOGY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-424-9101
Mailing Address - Fax:208-424-5072
Practice Address - Street 1:388 E. PARKCENTER BLVD. GEM STATE DERMATOLOGY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-424-9101
Practice Address - Fax:208-424-5072
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7247207N00000X
IDPA773363A00000X
IDPA-773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808380800Medicaid