Provider Demographics
NPI:1760473920
Name:JENSEN, MARK J (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:JENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:22530 SE 64TH PL
Mailing Address - Street 2:STE 140
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5353
Mailing Address - Country:US
Mailing Address - Phone:425-392-2020
Mailing Address - Fax:425-392-1657
Practice Address - Street 1:22530 SE 64TH PL
Practice Address - Street 2:STE 140
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5353
Practice Address - Country:US
Practice Address - Phone:425-392-2020
Practice Address - Fax:425-392-1657
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA1820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000109631Medicare PIN
WAT86872Medicare UPIN
WA8880096Medicare PIN
WA0200680001Medicare NSC