Provider Demographics
NPI:1205825445
Name:JENSEN, G F (OD)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:F
Last Name:JENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4924
Mailing Address - Country:US
Mailing Address - Phone:920-235-8500
Mailing Address - Fax:920-303-5547
Practice Address - Street 1:422 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4924
Practice Address - Country:US
Practice Address - Phone:920-235-8500
Practice Address - Fax:920-303-5547
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38504000Medicaid
WI38504000Medicaid
T62319Medicare UPIN
WI0194510001Medicare NSC
WI87339Medicare PIN