Provider Demographics
NPI:1891935177
Name:MARK J JENSEN OD PS
Entity Type:Organization
Organization Name:MARK J JENSEN OD PS
Other - Org Name:ISSAQUAH OPTOMETRIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-392-2020
Mailing Address - Street 1:22530 SE 64TH PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8992
Mailing Address - Country:US
Mailing Address - Phone:425-392-2020
Mailing Address - Fax:
Practice Address - Street 1:22530 SE 64TH PL
Practice Address - Street 2:SUITE 140
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8992
Practice Address - Country:US
Practice Address - Phone:425-392-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000109631Medicare PIN