Provider Demographics
NPI:1386206266
Name:RAFOOL, JENSEN ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:JENSEN
Middle Name:ELIZABETH
Last Name:RAFOOL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 CENTRAL HAVEN DR APT 403
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3797
Mailing Address - Country:US
Mailing Address - Phone:309-267-2622
Mailing Address - Fax:
Practice Address - Street 1:1470 TOBIAS GADSON BLVD STE 115
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4835
Practice Address - Country:US
Practice Address - Phone:845-556-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist