Provider Demographics
NPI:1891792370
Name:JENSEN, PAUL SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:SCOTT
Last Name:JENSEN
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:P.O. BOX 353
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-0353
Mailing Address - Country:US
Mailing Address - Phone:425-255-2020
Mailing Address - Fax:425-255-2028
Practice Address - Street 1:112 PELLY AVE N
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5713
Practice Address - Country:US
Practice Address - Phone:425-255-2020
Practice Address - Fax:425-255-2028
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1722TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2061467Medicaid
WAAB03693Medicare PIN
WA5793900001Medicare NSC
WAT70507Medicare UPIN