Provider Demographics
NPI:1851488126
Name:HENSEL, JERRY R (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:HENSEL
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 1:96 SWEET GUM ROAD
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870
Mailing Address - Country:US
Mailing Address - Phone:570-374-7904
Mailing Address - Fax:
Practice Address - Street 1:137 JPM RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9313
Practice Address - Country:US
Practice Address - Phone:570-523-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA536441OtherAETNA
PA50045022OtherCAPITAL BLUE
PA001563915Medicaid
PA831613OtherBLUE SHIELD
PA50045022OtherCAPITAL BLUE