Provider Demographics
NPI:1447313234
Name:JENSEN, RICHARD A (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:1100 OLIVE WAY
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:MS C4-OPT
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6840
Practice Address - Fax:206-515-5886
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5262JEOtherBLUE SHIELD #
WA2033116Medicaid
WAP00395658OtherRAILROAD MC#
WAUS7327863OtherAETNA PCP PIN
WA2033116Medicaid
WA8863082Medicare PIN