Individual
MRS. JACLYN GOLUS MENTZER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
388 E. PARKCENTER BLVD. GEM STATE DERMATOLOGY, BOISE, ID 83706
(208) 424-9101
(208) 424-5072
Mailing address
388 E. PARKCENTER BLVD. GEM STATE DERMATOLOGY, BOISE, ID 83706
(208) 424-9101
(208) 424-5072
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
M7247
ID
363A00000X
Physician Assistant
Primary
PA-773
ID
363A00000X
Physician Assistant
PA773
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
808380800
—
ID
Enumeration date
12/08/2008
Last updated
01/27/2020
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