Provider Demographics
NPI:1336148576
Name:JENSEN, CLARK J (OD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:J
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:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0687
Mailing Address - Country:US
Mailing Address - Phone:641-236-7502
Mailing Address - Fax:
Practice Address - Street 1:935 BROAD ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2047
Practice Address - Country:US
Practice Address - Phone:641-236-7502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142455Medicaid
IA14245Medicare PIN
IAT00865Medicare UPIN