Provider Demographics
NPI:1598188930
Name:G F JENSEN
Entity Type:Organization
Organization Name:G F JENSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:F
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-235-8500
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1506-35332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205825445Medicare UPIN