Healthcare Provider Details

I. General information

NPI: 1780731885
Provider Name (Legal Business Name): RONALD OWEN JENSEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78015 MAIN ST SUITE #107
LA QUINTA CA
92253-3420
US

IV. Provider business mailing address

78015 MAIN ST SUITE #107
LA QUINTA CA
92253-3420
US

V. Phone/Fax

Practice location:
  • Phone: 760-771-0715
  • Fax: 760-771-2033
Mailing address:
  • Phone: 760-771-0715
  • Fax: 760-771-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4972T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: