Provider Demographics
NPI:1134272586
Name:JENSEN, GEORGIANN KAE (OD)
Entity type:Individual
Prefix:
First Name:GEORGIANN
Middle Name:KAE
Last Name:JENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 ABERDEEN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4716
Mailing Address - Country:US
Mailing Address - Phone:763-757-7000
Mailing Address - Fax:763-757-3328
Practice Address - Street 1:12170 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55449-4716
Practice Address - Country:US
Practice Address - Phone:763-757-7000
Practice Address - Fax:763-757-3328
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1994152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5275237000Medicaid
MN5275237000Medicaid
MNT65654Medicare UPIN
MN1134272586Medicare NSC
MN1134272586Medicare PIN