Provider Demographics
NPI:1255411211
Name:JENSEN, NATHANIEL PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:PAUL
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 1:34 WOODCROSS DR APT 924
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2364
Mailing Address - Country:US
Mailing Address - Phone:920-740-6207
Mailing Address - Fax:
Practice Address - Street 1:280 HARBISON BLVD STE T
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2247
Practice Address - Country:US
Practice Address - Phone:803-732-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist