MEDICARE: DR. GARY L JENSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1610	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2200981	OTHER	MDMA2 MEDICA PIN
2	OD327JE	OTHER	BCMA BCBS PIN
3	411260738	OTHER	PABS CLARITY VISION PIN
4	OD327JE	OTHER	FIRST FIRST PLAN PIN
5	01020509	OTHER	BOIS PREFERRED ONE PIN
6	01020509	OTHER	PRE00 UNITED HEALTH PIN
7	2200980	OTHER	MCCS1 MEDICA PIN
8	OD327JE	OTHER	ANTHEM BCBS PIN
9	OD327JE	OTHER	FIRSD FIRST PLAN DISP PIN
10	0150730001	OTHER	ADMINISTAR FEDERAL(DMERC), INC.
11	2100694	OTHER	MDMA3 MEDICA PIN
12	2200980	OTHER	MDMA1 MEDICA PIN
13	411260738	OTHER	BCWP BCBS OF PENN PIN
14	OD327JE	OTHER	BCMN BCBS PIN
15	524223100	OTHER	MNMA MN MED ASSIST PIN
16	OD327JE	OTHER	BCMAD BCBS PIN
17	OD327JE	OTHER	COM COMP CARE PIN

General Provider Information

NPI Number	:	1770508426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY L JENSEN

Provider Business Mailing Address
First Line	:	11 NW FIRST AVE
Second Line	:
City	:	CHISHOLM
State	:	MN
Zip	:	55719-1811
Country	:	US
Telephone Number	:	218-254-4393
Fax Number	:	218-254-5471

Provider Business Practice Location Address
First Line	:	11 NW FIRST AVE
Second Line	:
City	:	CHISHOLM
State	:	MN
Zip	:	55719-1811
Country	:	US
Telephone Number	:	218-254-4393
Fax Number	:	218-254-5471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	01/05/2010

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Directions to “ DR. GARY L JENSEN ” Practice Location

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