Provider Demographics
NPI:1952384125
Name:JENSEN, CLARK ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:ALLEN
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 1:3101 WYOMING BLVD SW
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4543
Mailing Address - Country:US
Mailing Address - Phone:307-265-7008
Mailing Address - Fax:307-234-9405
Practice Address - Street 1:3101 WYOMING BLVD SW
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-4543
Practice Address - Country:US
Practice Address - Phone:307-265-7008
Practice Address - Fax:307-234-9405
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY166T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0803620001Medicaid
WYT44158Medicare UPIN
WY0803620001Medicare NSC