Provider Demographics
NPI:1417516279
Name:JENSEN, CORY JAMES (OD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:JAMES
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 1:52031 EAGLE VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FORD
Mailing Address - State:WA
Mailing Address - Zip Code:99013-9517
Mailing Address - Country:US
Mailing Address - Phone:509-844-5605
Mailing Address - Fax:
Practice Address - Street 1:601 W FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6699
Practice Address - Country:US
Practice Address - Phone:509-326-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60965247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAJENSECJ102N2OtherDRIVER LICENSE