Provider Demographics
NPI:1508803636
Name:JENSEN, KRISTI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:ANN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:57 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2401
Mailing Address - Country:US
Mailing Address - Phone:650-593-1661
Mailing Address - Fax:650-595-5203
Practice Address - Street 1:57 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2401
Practice Address - Country:US
Practice Address - Phone:650-593-1661
Practice Address - Fax:650-595-5203
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13817TLG152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
WAOD00003896152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFK015ZMedicare UPIN
WAV02195Medicare UPIN