Provider Demographics
NPI:1659436723
Name:JENSEN OPTOMETRISTS, P.L.L.C.
Entity Type:Organization
Organization Name:JENSEN OPTOMETRISTS, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:641-236-7502
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 BROAD ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2047
Practice Address - Country:US
Practice Address - Phone:641-236-7502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142455Medicaid
IAU01940Medicare UPIN
IA14246Medicare ID - Type UnspecifiedGROUP PROVIDER #
IA0265000001Medicare NSC
IAT00865Medicare UPIN
IA0142455Medicaid